msn 626 exam 1 practice questions

Question 1

Evidence-based strategies for prevention of catheter-associated urinary tract infections (CA-UTI) include all of the following except:

A. hand-washing should be performed immediately before and after any manipulation of the indwelling urinary catheter
B. insert indwelling urinary catheter using sterile equipement and aseptic technique
C. collect urine specimens from the distal end of the catheter
D. wear a mask at all times when in the room with a patient who has an indwelling urinary catheter

Answer 1

D.wear a mask at all times when in the room with a patient who has an indwelling urinary catheter

Explanation:
It is not necessary to wear a mask at all times when in the room with a patient who has an indwelling catheter. All of the other answer choices are evidence-based strategies to prevent CA-UTI.

Question 2

Which of the following aspects of nursing care is associated with decreasing risk of catheter-associated urinary tract infection (CA-UTI)?

A. utilizing antimicrobial urinary catheters instead of standard catheters
B. Prophylactic antibiotic administration
C. insertion of indwelling urinary catheters in all critically ill pts
D. Thorough daily assessment to determine the need for foley

Answer 2

D. Thorough daily assessment to determine the need for foley

Explanation:
Nursing-related care measures that decrease the risk of CA-UTI include thorough assessment to determine the need for indwelling catheter use, aseptic insertion technique, indwelling catheter care to minimize infection risk, and astute monitoring of patients with urinary catheters for signs of UTI.

Indwelling urinary catheters should be inserted only in those patients who need them, not in all critically ill patients. Though antimicrobial urinary catheters could reduce the risk of CA-UTI, consensus on the economic benefit compared to standard catheter use has not yet been determined. Not all patients with indwelling urinary catheters receive preventative antibiotics.

Question 3

Evidence-based strategies to prevent central line-associated bloodstream infections (CLA-BSI) include replacing the transparent central line dressing whenever damp, soiled, or loose or at least every:

A. 3 days
B. 7 days
C. 5 days
D. 2 days

Answer 3

B. 7 days

Explanation:
Evidence-based strategies for central line infection prevention include replacement of transparent dressing at least every seven days, or sooner if damp, loose, or soiled. Gauze dressings should be replaced if the patient is diaphoretic or if the site is bleeding or oozing, or at least every two days. The catheter site should be assessed every shift for redness, tenderness, pain, or exudate.

Question 4

Strategies for preventing the development of ventilator-associated pneumonia (VAP) in the critically ill patient include all of the following except:

A. implement an oral hygiene program that includes oral suctioning, teeth-brushing and use of Chlorhexidine gluconate
B. eliminate invasive devices and equipment ASAP
C. maintain a closed system on ventilator/humidifier circuits and routinely change the circuit
D. avoid supine position

Answer 4

C. maintain a closed system on ventilator/humidifier circuits and routinely change the circuit

Explanation:
Though the nurse should maintain a closed system on ventilator/humidifier circuits and avoid pooling of condensation or secretions in the tubing, changing the ventilator circuit should not be done routinely. Rather, only change the circuit when visibly soiled or malfunctioning. The other answer choices are prevention strategies.

Question 5

Of the following strategies, which is indicated to reduce the risk of central line-associated bloodstream infections (CLA-BSI)?

A. routinely replace CVC at scheduled intervals
B. replace IV tubing no more frequently than every 96hrs but at least every 7 days unless otherwise recommended by pharmacy based on meds
C. replace peripheral IV sites at least every 7 days but no more frequently than every 96 hrs
D. use of abc ointment at the insertion site

Answer 5

B. Replace intravenous tubing no more frequently than every 96 hours but at least every seven days unless otherwise recommended by pharmacy based on medication

Explanation:
IV tubing should be replaced no more frequently than every 96 hours but at least every seven days to prevent bacterial overgrowth infusing from the IV tubing itself into the central line.

Antibiotic ointment at the insertion site should be avoided because it can promote fungal infections and antibiotic resistance. Central lines should not be routinely replaced at scheduled intervals as this could increase the risk of infection. Peripheral IV sites should be replaced at least every 96 hours but no more frequently than every 72 hours. In small children, peripheral venous catheters should be maintained until the intravenous therapy is completed, unless infiltration or phlebitis occurs.

Question 6

A 45-year-old male is admitted to the medicine service for fatigue, fever, chills, and weight loss. He has a known history of AIDS. He has been off all of his medications for the past 6 months. His CD4+ count is less than 50/cells/μL. The AG-ACNP should:

A. immediately start previous regimen of ART
B. Treat current infection and delay ART until improved
C. start a new regimen of ART
D. start broad-spectrum abx and begin ART when afebrile

Answer 6

B. Treat current infection and delay ART until improved

explanation:
No treatment should be started when the patient is sick if the patient has been off a medication regimen, due to fear of reconstitution syndrome. In HIV infections, an exaggerated inflammatory response to a disease-causing microorganism can occur when the immune system starts to recover following treatment with ART. IRIS occurs in two forms: “unmasking” IRIS refers to the flare-up of an underlying, previously undiagnosed infection soon after ART is started; “paradoxical” IRIS refers to the worsening of a previously treated infection after ART is started. IRIS can be mild or life-threatening.

Question 7

Common manifestations associated with HIV acute retroviral syndrome include which of the following assessment findings:

A. goiter
B. cervical lymphadenopathy
c. janeway lesions
d. kaposi sarcoma

Answer 7

B. cervical lymphadenopathy

explanation:
Following acute HIV infection, high viral replication occurs in a variety of lymphatic sites and tissues. This will cause lymphadenopathy. Acute retroviral syndrome typically occurs 2 to 6 weeks post initial exposure. Patients will also experience rash, arthralgias, fever, and pharyngitis. A goiter is an enlarged thyroid gland the result of dysfunctional thyroid synthesis or thyroid adenoma or carcinoma. Janeway lesions are small vascular lesions found in patients with endocarditis. Kaposi sarcoma is an AIDS-associated malignancy and not typically associated with acute retroviral syndrome.

Question 8

A 74-year-old male with a history of prostate cancer is admitted to the hospital with progressive back pain which has progressively worsened over the past weeks. It is suspected that the patient has spinal cord compression secondary to vertebral metastasis. Common assessment findings associated with spinal cord compression are:

A. pain improves when the pt is supine
B. deep tendon reflexes are hypoactive
C. pain is relieved with straight leg raises
D. tingling sensation down the back when neck is flexed

Answer 8

D. tingling sensation down the back when neck is flexed

explanation:
Spinal cord compression is the second most common neurologic complication associated with cancers of the prostate, breast, and lung. Cord compression manifests with gradually worsening back pain around the level of involvement. Lhermitte’s sign is a tingling sensation down the back and upper and lower limbs upon flexing or extending the neck and often an early sign of cord compression. Spinal cord compression pain worsens when the patient is supine (unlike disk disease) and with straight leg raises. Deep tendon reflexes are likely to be brisk with motor involvement.

Question 9

A 44-year-old male with a history of HIV and not on any treatment verbalizes severe substernal burning without radiation and odynophagia. Upon exam the AG-ACNP notes oral thrush. The AG-ACNP suspects which of the following diagnoses:

A. GERD
B. Candida esophagitis
C. gastric ulcer perforation
d. esophageal cancer

Answer 9

B. candida esophagitis

Explanation:
Pain on swallowing and substernal burning are common symptoms with candida esophagitis. This is especially true when oral thrush is present. Patients with GERD have complaints of “heartburn” and could have dysphagia but oral candida would not be present. Patients with gastric ulcer perforation will present with severe abdominal pain that begins in the epigastrium and radiates throughout the entire abdomen. Patients with esophageal cancer typically have progressive dysphagia as an early symptoms and odynophagia with more advanced disease. Advanced esophageal will also present with pain radiating to chest and back with regurgitation and vomiting. Esophageal cancer is typically not a malignancy associated with HIV.

Question 10

An intubated patient is receiving enteral nutrition. Today she has a new onset fever, leukocytosis, and increased sputum production. Chest x-ray demonstrates right lower lobe (RLL) infiltrate. Which of the following interventions is most beneficial to decrease the incidence of this complication?

A. elevate HOB >30 degrees
B. prescribe sulcrafate (carafate)
C. mouth care with oral suctioning every shift
D. assessment of frequent gastric residuals

Answer 10

A. elevate HOB >30 degrees

explanation:
Head of bed elevation is a grade I recommendation for prevention of ventilator pneumonia. Carafate, H2 blockers, and PPIs are indicated to prevent gastric ulcers. Mouth care and oral suctioning should ideally be performed more often than every shift. (In addition, shift length varies by institution: Some are 8 hours, others are 12 hours.) Gastric residuals are a poor predictor in aspiration pneumonia.

Question 11

A patient was mechanically vented for 7 days for CAP and was extubated 2 days ago. His vitals and labs have been stable, but he failed the swallow evaluation by the speech therapist. What is the most appropriate intervention?

A. continue ICU monitoring and management
B. discharge pt to a long-term care facility
C. transfer the pt to subacute care unit
D. consult GI for PEG tube

Answer 11

C. transfer the pt to a subacute care unit

explanation:
This patient has had a long stay in the ICU, and has been extubated 2 days ago with demonstrated hemodynamic stability. Though he has failed the swallow evaluation, transfer to a subacute is appropriate. The patient does not need ICU management. Transfer to a long-term care facility is premature. Consulting GI for a PEG tube is premature as well. Reevaluation of swallowing in a few days is appropriate.

Question 12

While caring for an intubated 54-year-old male trauma patient on hospital day 6 who is on high levels of positive pressure ventilation, the AG-ACNP notices the patient’s fever curve and leukocytosis are increasing. Additionally she identifies increased bilateral diffuse opacifications on a morning chest x-ray, increased peak/plateau inspiratory pressures, and increasing oxygenation requirements. What is the most likely diagnosis and associated management strategy?

A.Spontaneous pneumothorax; needle decompression to second intercostal space midclavicular line and placement of a thoracotomy tube
B.Acute CHF exacerbation; administration of IV diuretic with consult to cardiology and transthoracic echocardiogram
C. ARDS; adjust mechanical ventilator to low tidal volume protocol and lung protective ventilation measures with a VAP protocol
D.Bilateral post-obstructive atelectasis; consult to pulmonology for immediate bronchoscopy

Answer 12

C. ARDS; adjust mechanical ventilator to low tidal volume protocol and lung protective ventilation measures with a VAP protocol

explanation:
The patient has developed ARDS and needs low tidal volume ventilation. Patients may develop a spontaneous pneumothorax due to ARDS or high levels of positive pressure ventilation, but pnuemothoracies cause increased PIP, not increased plateau pressures. Acute CHF additionally can present gradually, and may cause increased bilateral infiltrates on radiograph. CHF, however, usually does not cause an increase in PIP/plateau pressures along with an uptrending leukocytosis/fever curve. Bilateral postobstructive atelectasis can also cause increased PIP and bilateral obscuration on chest radiograph; however, it does not present with upward trending leukocytosis/fever curve.

Question 13

A 78-year-old male patient is admitted with sepsis secondary to a UTI. One month prior to this hospitalization he had been treated with IV antibiotics for a wound infection. He was intubated on admission. On day 4 of hospitalization he is diagnosed with VAP. He has no known allergies. Empiric coverage for VAP in this patient should include:

A. Piperacillin-tazobactam, cefepime, and levofloxacin
B. Piperacillin-tazobactam, linezolid, and vancomycin
C. Oxacillin, levofloxacin, and doxycycline
D.Piperacillin-tazobactam, meropenem, and vancomycin

Answer 13

D.Piperacillin-tazobactam, meropenem, and vancomycin

explanation:
In a patient with hospital associated pneumonia (HAP) who is at high risk for ventilator associated pneumonia (VAP), coverage with two antipseudomonal agents plus coverage for Staphylococcus aureus is recommended. If the patient is at high risk for MRSA, then coverage with vancomycin or linezolid is recommended. Patients who are at high risk for MRSA are patients who have been treated with antibiotics within the past 30 days, patients in units with prevalence of MRSA isolates greater than 20%, or previous positive culture for MRSA.

Question 14

A 42-year-old woman presents to the hospital with a probable diagnosis of CAP. Her chest x-ray shows a large pleural effusion. The AG-ACNP performs a thoracentesis, which results as follows:

Color: Viscous, cloudy

pH: 7.11

Protein: 5.8 g/dL

LDH: 285 IU/L

Glucose: 66 mg/dL

WBC: 3,800/mm3

RBC: 24,000/mm3

PMDs: 93%

Gram stain: Many PMN; no organism seen

What is the next step in managing this patient?

A. tube thoracostomy
B. Diuresis w lasix
C. Antiviral therapy
D. VAT

Answer 14

A. Tube Thoracostomy

Explanation:
All large pleural effusions complicated by pneumonia are most likely to be exudative. A tube thoracotomy includes loculated pleural fluid, pH below 7.2, pleural glucose less than 60 mg/dL, Gm+ or culture of pleural fluid, and the presence of pus. Diuresis would not help, as this is an inflammatory process, not a fluid issue. Antivirals are not indicated since this is a bacterial infection. VAT is not appropriate at this time.

Question 15

A 20-year-old college student presents with change in mental status, fever, chills, and a petechial rash. Vital signs: temperature 102.4°F, heart rate 120, respiratory rate 24, blood pressure 90/60. Upon exam, the AG-ACNP notes he is disoriented, lethargic, shows signs of dehydration, and has positive Kernig’s and Bbrudzinski’s signs. Blood cultures are sent, and lumbar puncture is performed. Results of the lumbar puncture demonstrated cloudy cerebrospinal fluid, with low glucose and high protein. The most likely diagnosis is:

A. Viral meningitis
B. Viral Encephalitis
C. Subarachnoid hemorrhage
D. Bacterial meningitis

Answer 15

D. Bacterial Meningitis

explanation:
This scenario is consistent with bacterial meningitis. Viral meningitis and encephalitis will have similar presentations, however will not have cloudy cerebrospinal fluid and glucose will be normal and the Gram stain will be negative. SAH may have change in mental status and neck pain and headache. SAH will have blood in the CSF and typically does not have fever or chills or petechial rash.

Question 16

An older adult patient who was admitted after a fall down a flight of stairs, sustaining multiple rib fractures, was admitted to the ICU for pain control and respiratory support with noninvasive ventilation. On hospital day 7, he developed a fever and increased oxygen requirements, and was intubated. Repeat CBC shows a rising white count to 16.5 with a bandemia, up from 11 yesterday. Chest x-ray shows worsening atelectasis with new air bronchograms in the right lower and middle lung fields. The AG-ACNP diagnoses this as:

A. progressive atelectasis
B. Hospital acquired pneumonia
C. healthcare- associated pneumonia
D. CAP

Answer 16

B. Hospital- Acquired Pneumonia

Explanation:
HAP is defined as pneumonia that is not incubating at the time of hospital admission and occurs 48 hours or more after admission. VAP is defined as a pneumonia occurring greater than 48 hours after endotracheal intubation. While this patient may have atelectasis, the presence of leukocytosis, bandemia, and air bronchograms are indicative of consolidation or an inflammatory process that is associated with pneumonia. CAP is defined as pneumonia that incubates within 48 hours of admission. The concept of healthcare associated pneumonia was removed in the 2016 HAP & VAP guidelines.

Question 17

An elderly woman admitted from a nursing home with septic shock related to a UTI. She had a prolonged ICU course complicated by AKI, non-STEMI and acute respiratory failure with failure to wean. She recovered from the septic shock but required prolonged mechanical ventilation for 14 days. She was about to be discharged to a long-term acute care hospital for continued ventilator weaning when she developed a new fever, tachycardia, and tachypnea. Repeat WBC was 10.5 and lactate was 2.9 mg/dL. Procalcitonin level was elevated. The AG-ACNP treats this patient with the following:

A. Ceftriaxone (Rocephin) and azithromycin (z-pack)
B. Vancomycin and piperacillin-tazobactam (zosyn)
C. Linsezolid (Zyvox), Ciprofloxacin (cipro), and gentamycin
D. vancomycin, piperacillin-tazobactam (zosyn), and levofloxacin (levaquin)

Answer 17

D. vancomycin, piperacillin-tazobactam (zosyn), and levofloxacin (levaquin)

explanation:
This patient has VAP. Treatment needs to include coverage for MRSA and double coverage for pseudomonas and Gram-negative organisms. Thus, vancomycin or linezolid would be appropriate coverage for MRSA. And piperacillin-tazobactam (Zosyn) and levofloxacin (Levaquin) would provide double coverage one from beta-lactam-based antibiotic and one without beta-lactam-based agents. Cipro and gentamycin are both nonbeta-lactam-based agents. Ceftriaxone and azithromycin are common treatments for CAP.

Question 18

A 50-year-old woman with a medical history of obesity, hypertension, and diabetes, is postoperative day 3 following an elective total hip replacement. Her foley catheter was removed on postoperative day 1. She is now mildly confused and incontinent of urine. The urinalysis shows: 3+ leukoesterase, 3+ nitrates, 200 WBCs. The AG-ACNP treats this with:

A.Sulfamethoxazole/trimethoprim (Bactrim)
B.Nitrofurantoin (Macrobid)
C. ceftriaxone (Rocephin)
D. Phenazopyridine (pryidium)

Answer 18

C. ceftriaxone (recephin)

explanation:
This is a complicated UTI and recommended treatment for a complicated UTI is a fluoroquinolone or beta-lactam agent. Nitrofurantoin and Bactrim are used to treat simple UTIs and Pyridium is used to manage discomfort. Women who have diabetes are more prone to UTIs.

Question 19

The AG-ACNP covering the bone marrow transplant unit is called by the nurse reporting a patient who had a transplant 5 days ago has a temperature of 100.4°F (38.0°C) and an absolute neutrophil count (ANC) less than 500/μL. The most important intervention to prevent death is for the AG-ACNP to:

A. order blood cultures
B. prescribe broad spectrum abx
C. prescribe filgrastim (Neupogen)
D. transfer pt to ICU

Answer 19

B. prescribe broad spectrum Abx

explanation:
This is a febrile patient with neutropenia, who is becoming septic. Prompt recognition and initiation of broad spectrum antibiotics is essential to prevent death. Blood cultures are important and will aid in determining the causative organism, but will not prevent death. Neupogen is indicated, but will not treat the source of infection. There is not sufficient data in the stem to determine if the patient meets ICU admission criteria.

Question 20

An adult woman was admitted for severe CAP. She had dehydration upon presentation for which she received 2 L lactated ringers over the first 24 hours. She is on day 3 of 7 of ceftriaxone and azithromycin. She is requiring less oxygen. Her BUN-to-creatinine ratio and WBC normalized on hospital day 2. She had three loose stools yesterday and today and is now complaining of abdominal pain. Her WBC is backup to 18,000 μ/L. The AG-ACNP suspects she is experiencing:

A. C. Diff infection
B. side effects from abx
C. gastroenteritis
D. treatment failure of pneumonia

Answer 20

A. C. Diff infection

explanation:
This patient likely has C. diff. Manifestations of C. diff infection include more than three loose stools per day and abdominal pain and leukocytosis greater than 15,000 μ/L, although patients can have a dynamic ileus, causing no stool. Side effects of antibiotics can cause diarrhea or loose stools; they would not cause a recurrent leukocytosis. Treatment failure of the pneumonia would not demonstrate improved oxygenation. Gastroenteritis is a less likely diagnosis in the inpatient setting.

Question 21

An older adult presents with a sudden onset of rash that rapidly progressed on his right lower leg. The patient has severe peripheral vascular disease with 3+ pitting edema bilaterally. A 1 cm open area, draining serous fluid, is noted on the lateral aspect of the left calf. Erythema and hyperthermia is noted on exam and the patient reports tenderness to palpation. The AG-ACNP initiates:

A. Penicillin
B. unna boot bilaterally
C. Enoxaprin (Lovenox) 1 mg/kg BID
D. Vanc and Zosyn

Answer 21

A. Penicillin

explanation:
A rapidly progressive rash is seen with streptococcal infections, for which penicillin is the best treatment option for this cellulitis. If the patient had systemic signs of infection such as fever, leukocytosis, or bandemia then vancomycin and piperacillin/tazobactam would be indicated to cover for sepsis and provide MRSA coverage. Other treatment options would include penicillin, ceftriaxone, or clindamycin. Unna boots are indicated for venous stasis ulcers; however, this is not sufficient treatment for this patient’s cellulitis. Lovenox is indicated in DVT.

Question 22

A patient admitted with septic shock related to CAP received the sepsis bundle, including central line placement, fluid resuscitation, vasopressor therapy, and broad spectrum antibiotics. The patient has resolved sepsis, weaned off vasopressors, and is completing 7-day course of antibiotics. On hospital day 7 the patient spiked a new fever to 103.3°F (39.6°C), heart rate 120, respiration rate 24, blood pressure 86/40. Chest x-ray shows resolving pneumonia, urinalysis is normal. Upon exam, the patient is warm and flushed; lungs are clear; abdomen (ABD) soft, nontender, nondistended. The most likely cause of this new fever is:

A. catheter- related UTI (CAUTI)
B. C. Diff
C. catheter related blood stream infection (CLABSI)
D. hospital acquired pneumonia

Answer 22

C. Catheter-related blood stream infection (CLABSI)

explanation:
Catheter-related blood stream infection is the most likely cause of this patient change of condition. The patient has a new episode of sepsis. Chest x-ray is improving, urinalysis is normal, and abdominal exam is benign, thus lowering the possibility of catheter-related UTI, Clostridium difficile infection, and hospital acquired pneumonia.

Question 23

The AG-ACNP is examining a male patient with a medical history of CHF and notices bilaterally lower extremity swelling, erythema, and warmth with nondraining blisters. The patient indicates that he has been running a low-grade fever with intermittent chills. The patient also reports that this is his first episode of these symptoms and he does not have a history of recent hospitalization and lives at home. The patient’s vital signs are stable except for a temperature of 100.4°F. Based on this information, the AG-ACNP prescribes which of the following medications in this patient with NKDA:

A. IV vanc
B. IV Cefazolin
C. IV extended spectrum penicillin
D. IV Fluoroquinolone

Answer 23

B. IV cefazolin

explanation:
The patient likely has cellulitis, which is a superficial inflammation of the skin and underlying tissues and is characterized by erythema, warmth, and tenderness of the involved area. The most common organisms associated with this presentation are streptococci or methicillin-sensitive staphylococcal aureus. According to the IDSA, cefazolin is the recommended drug of choice among others that do not include broad spectrum penicillin or fluoroquinolones. There is no need for extended spectrum in a patient with a first episode; in addition, one must also consider common organisms that are likely causing the cellulitis. Vancomycin is recommended for MRSA skin and soft tissue infections, and the patient does not have risk factors of concern for MRSA.

Question 24

An older adult man presented from home with a complaint of worsening shortness of breath and white sputum production. Chest x-ray was clear and he was admitted with a COPD exacerbation and received oxygen therapy, albuterol nebulizers, and IV steroids. On hospital day 1, the AG-ACNP notes he developed a new fever, worsening leukocytosis, and increased sputum production. The AG-ACNP obtains a repeat chest x-ray that now reveals a new left lower lobe infiltrate. The AG-ACNP diagnoses the patient with:

A. aspiration pneumonitis
B. hospital acquired pneumonia
C. healthcare associated pneumonia
D. CAP

Answer 24

D. CAP

explanation:
CAP is defined as pneumonia that incubates within 48 hours of admission. The concept of healthcare-associated pneumonia was removed in the 2016 HAP and VAP guidelines. Hospital-acquired pneumonia is defined as pneumonia that is not incubating at the time of hospital admission and occurs 48 hours or more after admission. VAP is defined as a pneumonia occurring greater than 48 hours after endotracheal intubation. There is no indication in the stem indicating this patient aspirated, furthermore, aspiration typically is seen in the right lower lobe because the left mainstem bronchus is more angulated due to the location of the heart.

Question 25

An older woman admitted 2 weeks ago to the ICU in septic shock has received broad spectrum antibiotics of piperacillin/tazobactam (Zosyn), levofloxacin (Levaquin), and vancomycin for 10 days. She received fluid resuscitation and vasopressor therapy for 5 days. Her recovery has been slow due to failure to respond to treatments and failure to wean off the ventilator. Her WBC remains steady at 12,000/μL and she remains afebrile. Blood cultures are negative; chest x-ray is clear. Urinalysis demonstrates WBCs, 3; negative for ketones, nitrates, and leukoesterase; but positive for hyphae. The AG-ACNP prescribes:

A. fluconazole (Diflucan)
B. Amphotericin B bladder irrigation
C. Impenim (Primaxin) and Vanc
D. Ceftriaxone

Answer 25

A. Fluconazole (Diflucan)

explanation:
This patient has a fungal urinary tract. Hyphae represent budding yeast. Candida infections are common in ICU patients who have received broad spectrum antibiotics. They are usually asymptomatic or may not be able to communicate symptoms due to intubation and ventilator use. Amphotericin bladder irrigation is not indicated. Ceftriaxone is indicated for complicated bacterial UTIs. This patient does not need imipenim or vancomycin.

Question 26

A 54-year old male diabetic patient is admitted to the medical unit secondary to left lower extremity cellulitis with an infected ulcer. The patient was working in his garage and sustained a small scratch to his left leg. The scratch quickly increased in size with noted redness and swelling to the left lower extremity. The wound was cleansed in the ED, the patient was started on IV clindamycin and ceftriaxone and admitted to the medical unit. On day 2 of admission the AG-ACNP notes the patient to be febrile, with an increasing WBC count. The patient verbalizes worsening pain with a tingling sensation to the lower extremity without relief from oral Vicodin. Upon exam, the left lower extremity increased from prior demarcation with persistent erythema and palpable crepitus to the lateral aspect of the leg. Based on this information the most important intervention at this time would be to:

A. increase pain meds to IV dilaudid
B. Change to penicillin G 4 million units IV Q4hr and clindamycin 900mg IV q8hr
C. Add IV vanc. 20mg/kg IV BID to abx regimen STAT, goal trough 15-20
D. order STAT x-ray of the patients Left leg

Answer 26

B. Change to penicillin G 4 million units IV Q4hr and clindamycin 900mg IV q8hr

explanation:
Diabetic patients are at increased risk for necrotizing fasciitis. Necrotizing fasciitis is a progressive and rapidly spreading inflammatory reaction that involves the tissue between the skin and the muscle (superficial fascia). The initial skin lesion is often small and trivial but rapidly spreads. Patients report increased pain out of proportion to what one might expect for this type of injury. The signs and symptoms are readily apparent (do not need radiology to confirm; CT would be diagnostic test of choice) in this situation and time is of essence. Immediate change to high-dose penicillin and clindamycin is imperative to treat streptococcus. Surgical intervention is a major therapeutic modality for necrotizing fasciitis and should also be obtained. Vancomycin is narrow spectrum and would not cover possible anaerobic or Gram-negative bacilli organisms.

Question 27

A 22-year-old college football player is brought to the ED after 4 days of an intermittent fever, headache, and stiffness in his neck. He has become confused, and his parents are at the bedside. The AG-ACNP requests consent from the parents to obtain which of the following diagnostic tests:

A. CT scan of the cervical spine
B. Brudzinski’s and Kernigs signs
C. lumbar puncture
D. MRI of brain

Answer 27

C. Lumbar puncture

explanation:
The most likely diagnosis is meningitis. Thus, a lumbar puncture and the associated testing will confirm the diagnosis of meningitis. A CT scan of the cervical spine will not confirm diagnosis of meningitis. But it can rule out bony injury of the spine; however, there is no history in the stem indicating an injury occurred. An MRI would confirm presence of an abscess or tumor as the cause of the symptoms, but these are not the most likely diagnosis. An MRI or magnetic resonance angiography will not confirm diagnosis of meningitis. Eliciting Brudzinski’s and Kernig’s signs are assessments and, when positive, leads the diagnostician toward the diagnosis of meningitis, but do not confirm diagnosis. Furthermore, these do not warrant consent to perform.

Question 28

A patient has been admitted from home with a peripherally inserted central catheter line for parenteral nutrition. She is lethargic, febrile, tachycardic, and hypotensive, requiring fluid resuscitation and vasopressor support. Blood cultures revealed heavy growth of Gram-positive cocci at 10 hours and the PICC line was immediately removed. This is an example of:

A. resuscitation therapy
B. source control
C. early goal-directed therapy
D. inotrope therapy

Answer 28

B. source control

Explanation:
This is an example of source control, which is one of the tenets in the treatment of sepsis. Will resuscitation therapy, early goal direct therapy, and inotrope therapy are part of the bundle for sepsis, it is important to look at source control, which is the removal of the catheter.

Question 29

A 60-year-old female motor vehicle crash victim presented to the ED with a fractured humorous and evisceration of the small bowel. Vitals were stable upon arrival and she had immediate restorative surgery to correct her injuries. Preoperatively she was placed on empiric antibiotic coverage, had a urinary catheter placed, and was intubated. While conducting rounds on postoperative day 2, the AG-ACNP notices the patient has developed mild hypotension, fever, and leukocytosis. Understanding the patient is at risk for hospital-acquired infections, what is the best way to prevent development of an iatrogenic infection for this patient?

A. daily cultures while IV abx are escalated to treat suspected infections
B. adhere to evidence-based care bundles and review daily in multidisciplinary rounds
C. replace invasive lines every 7 days
D. adopt policies from larger institutions to help reduce rates of infection because they have reduced their hospital acquired infection rate

Answer 29

B. adhere to evidence-based care bundles and review daily in multidisciplinary rounds

explanation:
Use of the A, B, C, D, E care bundles in an interdisciplinary manner has shown decreases in length of stay, complications, infections, and mortality. Daily cultures and escalation of antibiotics can have adverse outcomes. The goal is to deescalate antibiotics as soon as possible. Changing lines after an established time is not appropriate; lines do not need to be changed unless a cause is identified. Adapting a policy from a larger facility that has not been vetted appropriately through your institution can have adverse effects as different hospitals have differing populations and sizes.

Question 30

An 82-year-old female is being cared for on a medical unit for aspiration pneumonia. She is receiving broad-spectrum antibiotics and is primarily bedridden. The nurse caring for the patient tells the AG-ACNP that upon removing the patient’s brief, she noticed redness to the lower back. Upon assessment the AG-ACNP notices diffuse erythematous patches to the lower back extending into the gluteal fold with small areas of pustules in a satellite pattern. The patient denies pain but states she can feel some irritation. Based upon this assessment, the AG-ACNP orders:

A. acyclovir
B. Nystatin powder
C. transparent film
D. hydrocortisone 1% cream

Answer 30

B. Nystatin Powder

explanation:

This patient is at risk for fungal skin infection related to administration of broad-spectrum antibiotics and bedridden status wearing a brief. Candidiasis is most common fungal skin organism. Candida pustules can develop on the backs of bedridden patients and appear as red patches, sometimes with erosion, and peripheral satellite pustules. Nystatin powder is a topical polyene that is used to treat fungal skin infections. Acyclovir is prescribed for herpes zoster and these lesions are typically grouped vesicles on an erythematous base along a dermatome. Transparent film will protect the area from friction but will not decrease the fungal load. Topical steroids are used to decrease inflammation and itching but will not inhibit the synthesis of ergosterol (an essential component of the fungal cytoplasmic membrane).

Question 31

The AG-ACNP is caring for a patient who is on mechanical ventilation. Which of the following is a strategy prevents ventilator-associated pneumonia (VAP)?

A. change the vent circuit every 24 hrs
B. perform spontaneous breathing trials every 24 hrs
C. interrupt sedation once every 72 hrs
D. perform spontaneous breathing trials every 48 hrs

Answer 31

B. perform spontaneous breathing trials every 24 hrs

explanation:

Daily spontaneous breathing trials are associated with extubation 1 to 2 days earlier than usual care and are a level 1 recommendation for prevention of VAP. Interruption of sedation daily is also a level 1 recommendation and should be paired with spontaneous breathing trials. There is no evidence to support that changing ventilator circuits on a regular basis decreased VAP rates and is costly, therefore changing only when visibly soiled or when there is a malfunction is the current recommendation.

Question 32

The AG-ACNP is seeing a patient with a history of HIV who is admitted for treatment of pneumonia. His CD4 count upon admission is less than 50 cells/μL. He sees a story on the news about a measles outbreak in the state. He inquired about receiving the MMR vaccine to protect himself. The AG-ACNP’s best response is:

A. “The MMR is live vaccine and with your low CD4 count, you may become infected
B. Yes, we can give you the MMR at the time of discharge
C. We can consider the MMR once your pneumonia is resolved
D. the MMR is contraindicated for you because your CD4 count is so high

Answer 32

A. the MMR is a live vaccine and with your low CD4 count, you may become infected

explanation:
The MMR is a live vaccine and is contraindicated in patients with CD4 count less than 200 cells/μL. It is also contraindicated in patients who are receiving chemotherapy.

Question 33

Preventive measures to decrease the number of hospital-acquired pneumonia include which of the following? I.Patient precautions to reduce aspiration II.Health-care worker hand washing III.Reduction in vaccines against particular infections

A. 2 & 3
B. 1,2,3
C. 1 & 2
D. 1 & 3

Answer 33

C 1 & 2

Question 34

You are called to the emergency room to evaluate an otherwise healthy 18-year-old female whose chief complaints are fever, malaise, and difficulty breathing. As you enter the room, the physician informs you that he suspects community-acquired pneumonia. Which of the following is the most likely causative agent?

A. H. influenza
B. S. pneumoniae
C. legionella
D. Chlamydia

Answer 34

D. chlamydia

Question 35

Treatment of pneumonia caused by S. pneumoniae includes all of the following except:

A. Levofloxacin
B. Penicillin
C. Erythromycin
D. Doxycycline

Answer 35

B Penicillin

Question 36

Health-care-associated pneumonia is a greater risk to which of the following?

A. those who have underlying cardiopulmonary dx
B. those who are receiving mechanical ventilation
C. those who have undergone thoracic or abd surgery
D. those who are immunosuppressed

Answer 36

B. those who are receiving mechanical ventilation

Question 37

Which of the following should be administered to the patient who has health-care-associated pneumonia caused by Staphylococcus aureus and who is resistant to routine treatment?

A. aminoglycosides
B. Vanc
C. erythromycin
D. Fluoroquinolone

Answer 37

B Vanc