6B Competency Exam: Critical Care & Fluids

Front 1

A patient picks up a prescription for an Epipen for her son. Which of the following ratio strengths is used for epinephrine given by intramuscular administration?

Answer

A1:500

B1:1,000

C1:10,000

D1:100,000

E1:1,000,000

Back 1

B1:1,000

Front 2

Which of the following is not an IV hemostatic agent?

Answer

AAmicar

BKcentra

CProfilnine SD

DNovoSeven

EAmidate

Back 2

EAmidate

Front 3

MD is an elderly patient admitted for altered mental status. His admission serum sodium is 115 mEq/L. MD is started onVaprisol (loading dose and continuous infusion). The next day his serum sodium is 129 mEq/L. MD is at risk for which of the following adverse effects?

Answer

AProgressive multifocal leukoencephalopathy (PML)

BAcute quadriplegic myopathy syndrome (AQMS)

CDiabetes insipidus (DI)

DOsmotic demyelination syndrome (ODS)

EDisseminated intravascular coagulation (DIC)

Back 3

DOsmotic demyelination syndrome (ODS)

Front 4

What is the correct definition and rationale for using an inotropic agent in a patient with shock syndrome?

Answer

ATo increase cardiac contraction, to increase blood flow out of the heart (CO).

BTo decrease cardiac contraction, in order to provide rest to a failing heart.

CTo increase the heart rate, in order to reverse bradycardia.

DTo decrease the heart rate, in order to reverse tachycardia.

ETo increase systemic vascular resistance, to decrease or reverse tachypnea

Back 4

ATo increase cardiac contraction, to increase blood flow out of the heart (CO).

Front 5

A patient in the ICU with shock is receiving a norepinephrine infusion. What is the purpose of using norepinephrine in this setting?

Answer

ATo decrease cardiac output, increase blood flow to vital organs, and increase blood pressure

BTo increase cardiac output, increase blood flow to vital organs, and increase blood pressure

CTo increase cardiac output, decrease blood flow to vital organs, and increase blood pressure

DTo increase cardiac output, increase blood flow to vital organs, and decrease blood pressure

ETo vasodilate in the kidney for nephroprotection, and decrease blood pressure

Back 5

BTo increase cardiac output, increase blood flow to vital organs, and increase blood pressure

Front 6

A physician wishes to use morphine in a patient with a creatinine clearance of 20 mL/minute. The patient is in severe pain and requires analgesia. Choose the correct statement/s: (Select ALL that apply.)

Answer

AIt would be preferable to use MS Contin, crushed and placed into the g-tube

BMorphine has an active metabolite that can accumulate with renal impairment.

CMorphine cannot be used with this degree of renal impairment.

DMeperidine would be a better choice in this patient.

EThe patient will be at an increased risk of respiratory depression versus a patient with normal renal function.

Back 6

BMorphine has an active metabolite that can accumulate with renal impairment.

EThe patient will be at an increased risk of respiratory depression versus a patient with normal renal function.

Front 7

Which of the following represent risks associated with IVIG therapy? (Select ALL that apply.)

Answer

AAcute renal damage

BInfusion reactions

CAcute liver damage

DFever

EPulmonary fibrosis

Back 7

AAcute renal damage

BInfusion reactions

DFever

Front 8

Which of the following are crystalloids? (Select ALL that apply.)

Answer

ASodium chloride

B5% Albumin

CLactated Ringer's

DDextrose

EDextran

Back 8

ASodium chloride

CLactated Ringer's

DDextrose

Front 9

Which of the following agents are used as ICU sedatives? (Select ALL that apply.)

Answer

APrecedex

BMidazolam

CAtivan

DDiprivan

ELevophed

Back 9

APrecedex

BMidazolam

CAtivan

DDiprivan

Front 10

A patient with acute decompensated heart failure is receiving milrinone. Which of the statements concerning milrinone are correct? (Select ALL that apply.)

Answer

AMilrinone is a positive inotrope and increases contractility in the heart.

BMilrinone is an alpha-2 agonist.

CMilrinone is a vasodilator.

DMilrinone is administered IV only.

EMonitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.

Back 10

AMilrinone is a positive inotrope and increases contractility in the heart.

CMilrinone is a vasodilator.

DMilrinone is administered IV only.

EMonitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.

Front 11

A patient arrives at the emergency department after a severe MVA. The patient's blood pressure is low and he is in shock. The physician wants to start fluid resuscitation with a colloid on this patient immediately. Which of the following agents are colloids? (Select ALL that apply.)

Answer

ANormal saline

BHydroxyethyl starch

CLactated Ringer's

DDextran

EAlbumin

Back 11

BHydroxyethyl starch

DDextran

EAlbumin

Front 12

Which of the following statements concerning rocuronium, vecuronium and cisatracurium is incorrect?

Answer

AAccording to ISMP, these are all classified as "HIGH-RISK" medications.

BThese agents are paralytics, or neuromuscular blocking agents (NMBAs).

CThese drugs provide a high degree of sedation.

DThese agents should have a warning applied to the bag, such as: WARNING: PARALYZING AGENT.

EThe non-depolarizing neuromuscular blockers bind to the acetylcholine receptor and block the action of acetylcholine.

Back 12

CThese drugs provide a high degree of sedation.

Front 13

Which of the following medications is a vasopressor?

Answer

ADuloxetine

BPhenylephrine

CNovoSeven

DAmiodarone

EAdenosine

Back 13

BPhenylephrine

Front 14

A patient with end-stage alcoholic cirrhosis is admitted to the medical floor. His serum sodium level is 122 mEq/L. On physical exam he has ascites and peripheral edema, but only mild shortness of breath. What is the preferred treatment for this patient’s hyponatremia?

Answer

ASodium chloride tablets by mouth – start now.

B0.9% NaCl – start when serum sodium level drops below 120 mEq/L.

CDiuresis and fluid restriction – start now.

DDesmopressin – start when serum sodium drops below 115 mEq/L.

ELactated Ringer’s – start now.

Back 14

CDiuresis and fluid restriction – start now.

Front 15

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.

Allergies: NKDA

Medications:

Norvasc 10 mg PO daily

Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)

Exelon patch 9.5 mg/24 hr

Namenda 5 mg BID

Lantus 10 units at HS

Novolin R sliding scale PRN (scale not documented on transfer records)

Calcium supplement (dose not documented on transfer records)

Vitals:

Height: 5’2” Weight: 136 pounds

BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2/14:

Na (mEq/L) = 138 (135 – 145)

K (mEq/L) = 3.6 (3.5 – 5)

Cl (mEq/L) = 100 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 20 (7 – 20)

SCr (mg/dL) = 1.1 (0.6 – 1.3)

Glucose (mg/dL) = 187 (100 – 125)

Ca (mg/dL) = 8.7 (8.5 – 10.5)

Mg (mEq/L) = 1.3 (1.3 – 2.1)

PO4 (mg/dL) = 2.2 (2.3 – 4.7)

A1C (%) = 8.9

Albumin (g/dL) = 3.6 (3.5 – 5)

Labs on Hospital Admission 12/15/14:

Na (mEq/L) = 135 (135 – 145)

K (mEq/L) = 3.1 (3.5 – 5)

Cl (mEq/L) = 99 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 42 (7 – 20)

SCr (mg/dL) = 1.4 (0.6 – 1.3)

Glucose (mg/dL) = 169 (100 – 125)

Ca (mg/dL) = 8.8 (8.5 – 10.5)

Mg (mEq/L) = 1.0 (1.3 – 2.1)

PO4 (mg/dL) = 1.9 (2.3 – 4.7)

A1C (%) = 8.8

Albumin (g/dL) = 2.9 (3.5 – 5)

Tests:

EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending.

Question:

The ICU staff will monitor LS for delirium during her stay. Which statement is correct regarding ICU delirium?

Answer

ADelirium is rare in ventilated ICU patients.

BHaloperidol is recommended for prophylaxis and treatment of ICU delirium.

CProviding sedation with Ativan as opposed to Precedex may reduce the incidence of delirium.

DSeroquel may increase duration of delirium.

EEarly mobilization and environmental control are recommended to prevent delirium.

Back 15

EEarly mobilization and environmental control are recommended to prevent delirium.

Front 16

A patient in septic shock is unresponsive to repeated doses of epinephrine and his blood pressure continues to decline. The decision is made to initiate an intravenous vasopressin drip. What is the correct receptor pharmacology that explains the utility of vasopressin in the maintenance of blood pressure?

Answer

AAlpha-1 agonist

BBeta-1 agonist

CVasopressin agonist

DVasopressin antagonist

EDopamine-1 agonist

Back 16

CVasopressin agonist

Front 17

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.

Allergies: NKDA

Medications:

Norvasc 10 mg PO daily

Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)

Exelon patch 9.5 mg/24 hr

Namenda 5 mg BID

Lantus 10 units at HS

Novolin R sliding scale PRN (scale not documented on transfer records)

Calcium supplement (dose not documented on transfer records)

Vitals:

Height: 5’2” Weight: 136 pounds

BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2/14:

Na (mEq/L) = 138 (135 – 145)

K (mEq/L) = 3.6 (3.5 – 5)

Cl (mEq/L) = 100 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 20 (7 – 20)

SCr (mg/dL) = 1.1 (0.6 – 1.3)

Glucose (mg/dL) = 187 (100 – 125)

Ca (mg/dL) = 8.7 (8.5 – 10.5)

Mg (mEq/L) = 1.3 (1.3 – 2.1)

PO4 (mg/dL) = 2.2 (2.3 – 4.7)

A1C (%) = 8.9

Albumin (g/dL) = 3.6 (3.5 – 5)

Labs on Hospital Admission 12/15/14:

Na (mEq/L) = 135 (135 – 145)

K (mEq/L) = 3.1 (3.5 – 5)

Cl (mEq/L) = 99 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 42 (7 – 20)

SCr (mg/dL) = 1.4 (0.6 – 1.3)

Glucose (mg/dL) = 169 (100 – 125)

Ca (mg/dL) = 8.8 (8.5 – 10.5)

Mg (mEq/L) = 1.0 (1.3 – 2.1)

PO4 (mg/dL) = 1.9 (2.3 – 4.7)

A1C (%) = 8.8

Albumin (g/dL) = 2.9 (3.5 – 5)

Tests:

EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending.

Question:

LS requires fluid resuscitation. Which of the following is the best recommendation?

Answer

AHespan

BDextrose 5%

CNaCl 0.9%

DAlbumin 25%

EDextran 70

Back 17

CNaCl 0.9%

Front 18

Select the correct concentration of epinephrine that should be used to mix solutions intended for intravenous administration:

Answer

A1:2,500

B1:1000

C1:10,000

D1:100,000

E1:1,000,000

Back 18

C1:10,000

Front 19

The pharmacist receives an order for Precedex. Which of the following is an appropriate generic substitution for Precedex?

Answer

ACisatracurium

BKetamine

CDexmedetomidine

DPropofol

EDexamethasone

Back 19

CDexmedetomidine

Front 20

The boxed warning for IVIG products contains the following warning: Associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Administer IV at minimum concentration available and minimum rate of infusion in patients predisposed to acute renal failure; IVIG products containing sucrose as a stabilizer account for a disproportionate share of case reports involving renal failure. Choose the correct statements. (Select ALL that apply.)

Answer

AMost cases of renal damage with IVIG therapy have been with IVIG products that contain sucrose.

BPatients who have diabetes, are elderly, or have pre-existing renal damage are at higher risk for renal damage.

CAvoid concurrent use of gentamicin therapy, if possible.

DIn patients with renal disease, use a lower rate of infusion, and consider a lower dosage.

EAvoid concurrent use of vancomycin therapy, if possible.

Back 20

AMost cases of renal damage with IVIG therapy have been with IVIG products that contain sucrose.

BPatients who have diabetes, are elderly, or have pre-existing renal damage are at higher risk for renal damage.

CAvoid concurrent use of gentamicin therapy, if possible.

DIn patients with renal disease, use a lower rate of infusion, and consider a lower dosage.

EAvoid concurrent use of vancomycin therapy, if possible.

Front 21

A patient is admitted with significant hyponatremia (Na = 125). The provider would like to use tolvaptan. Which of the following statements is correct?

Answer

ATolvaptan is available IV only.

BTolvaptan is a first-line agent for treatment of hyponatremia.

CSodium should be corrected at a rate of 12 mEq/hr while on tolvaptan.

DThe brand name for tolvaptan is Vaprisol.

ETolvaptan use should be limited to 30 days due to potential for hepatotoxicity.

Back 21

ETolvaptan use should be limited to 30 days due to potential for hepatotoxicity.

Front 22

Hemostatic agents prevent blood loss. Which of the following statements concerning hemostatic agents are correct? (Select ALL that apply.)

Answer

ANewer hemostatic agents are reducing the need for transfusions.

BThe most common adverse events from the use of hemostatic agents are a drop in hemoglobin and anemia.

CPatients receiving hemostatic agents are at low risk of clotting.

DRecombinant thrombin (Recothrom) is not associated with the risk of disease transmission (such as Creutzfeld-Jakob disease) and is less immunogenic than previous thrombin formulations.

ETranexamic acid is a hemostatic agent used for both heavy menstrual bleeding and hemophilia-associated bleeding; it comes as both an oral and injectable.

Back 22

ANewer hemostatic agents are reducing the need for transfusions.

DRecombinant thrombin (Recothrom) is not associated with the risk of disease transmission (such as Creutzfeld-Jakob disease) and is less immunogenic than previous thrombin formulations.

ETranexamic acid is a hemostatic agent used for both heavy menstrual bleeding and hemophilia-associated bleeding; it comes as both an oral and injectable.

Front 23

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.

Allergies: NKDA

Medications:

Norvasc 10 mg PO daily

Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)

Exelon patch 9.5 mg/24 hr

Namenda 5 mg BID

Lantus 10 units at HS

Novolin R sliding scale PRN (scale not documented on transfer records)

Calcium supplement (dose not documented on transfer records)

Vitals:

Height: 5’2” Weight: 136 pounds

BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2/14:

Na (mEq/L) = 138 (135 – 145)

K (mEq/L) = 3.6 (3.5 – 5)

Cl (mEq/L) = 100 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 20 (7 – 20)

SCr (mg/dL) = 1.1 (0.6 – 1.3)

Glucose (mg/dL) = 187 (100 – 125)

Ca (mg/dL) = 8.7 (8.5 – 10.5)

Mg (mEq/L) = 1.3 (1.3 – 2.1)

PO4 (mg/dL) = 2.2 (2.3 – 4.7)

A1C (%) = 8.9

Albumin (g/dL) = 3.6 (3.5 – 5)

Labs on Hospital Admission 12/15/14:

Na (mEq/L) = 135 (135 – 145)

K (mEq/L) = 3.1 (3.5 – 5)

Cl (mEq/L) = 99 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 42 (7 – 20)

SCr (mg/dL) = 1.4 (0.6 – 1.3)

Glucose (mg/dL) = 169 (100 – 125)

Ca (mg/dL) = 8.8 (8.5 – 10.5)

Mg (mEq/L) = 1.0 (1.3 – 2.1)

PO4 (mg/dL) = 1.9 (2.3 – 4.7)

A1C (%) = 8.8

Albumin (g/dL) = 2.9 (3.5 – 5)

Tests:

EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending.

Question:

Which statement is correct regarding LS’s electrolyte abnormalities on 12/15/14? (Select ALL that apply.)

Answer

ALasix may have caused the hypokalemia and hypomagnesemia.

BReplacement of LS’s body stores of magnesium will be complete after one dose of IV magnesium sulfate.

CHypophosphatemia is considered severe and usually symptomatic when the serum phosphorus level is < 2 mg/dL.

DHypomagnesemia should be treated IV when serum magnesium level is < 1 mEq/L with seizures or arrhythmias.

EA drop of 1 mEq/L in serum potassium (below 3.5 mEq/L) represents a total body deficit of 100 – 400 mEq.

Back 23

ALasix may have caused the hypokalemia and hypomagnesemia.

DHypomagnesemia should be treated IV when serum magnesium level is < 1 mEq/L with seizures or arrhythmias.

EA drop of 1 mEq/L in serum potassium (below 3.5 mEq/L) represents a total body deficit of 100 – 400 mEq.

Front 24

JH is a 55 year old male who will be receiving his third IVIG treatment for autoimmune encephalopathy. He reports that he had been receiving steroid therapy for many years, but was changed to IVIG the previous fall when the symptoms worsened. He has presented to the infusion room. The pharmacist cannot locate the referring doctor's paperwork and will attempt to conduct a pre-screening prior to the treatment. Which of the following screening questions should the pharmacist ask JH? (Select ALL that apply.)

Answer

ADid you use any medications prior to the treatment to help lessen the side effects?

BWhat is the name of the IVIG medication received previously, and are you aware of the dose?

CIs anyone in the house presently immune-compromised (such as cancer or HIV-infected persons?)

DAre there any small infants in the house?

EDid you develop any reactions to the medication, either during the infusion, or afterwards?

Back 24

ADid you use any medications prior to the treatment to help lessen the side effects?

BWhat is the name of the IVIG medication received previously, and are you aware of the dose?

EDid you develop any reactions to the medication, either during the infusion, or afterwards?

Front 25

Which of the following statements is true of colloids and crystalloids?

Answer

ACrystalloids cause more adverse reactions than colloids.

BColloids improve mortality in shock when compared to crystalloids.

CColloids are commonly used for maintenance hydration and to replace fluid losses.

DColloids are more expensive than crystalloids.

ECrystalloids are large molecules that primarily remain in the intravascular space.

Back 25

DColloids are more expensive than crystalloids.

Front 26

Which of the following statements concerning IVIG is correct?

Answer

AIVIG is now available as inexpensive generic formulations.

BIVIG is a form of active immunity.

CAntibodies recognize antigens on foreign targets, such as bacteria.

DIt takes 10 human donors to make one dose of IVIG.

EIntravenous immunoglobulins contain a mixture of approximately 50% IgG and 50% IgM.

Back 26

CAntibodies recognize antigens on foreign targets, such as bacteria.

Front 27

Choose the correct statement concerning neuromuscular blocking agents:

Answer

APatients do not need to be on mechanical ventilation to receive a neuromuscular blocker.

BPatients should receive sedation and analgesia prior to the use of neuromuscular blockers.

CNo monitoring is needed when using neuromuscular blockers.

DThe Institute for Safe Medication Practices (ISMP) does not include neuromuscular blockers as medications that can cause significant harm, but they do include opioids.

EThey should be used in the majority of the patients in the ICU.

Back 27

BPatients should receive sedation and analgesia prior to the use of neuromuscular blockers.

Front 28

A young man with immune thrombocytopenia recently had transient intravascular hemolysis during intravenous gamma globulin treatment. The hemolysis was mediated by anti-A antibody present in the gamma globulin treatment. What signs and symptoms could indicate hemolysis? (Select ALL that apply.)

Answer

ANegative Direct Coombs test

BBlood in the stool

CPositive Direct Coombs test

DBlood in the urine

EPositive ANA test

Back 28

CPositive Direct Coombs test

DBlood in the urine

Front 29

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.

Allergies: NKDA

Medications:

Norvasc 10 mg PO daily

Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)

Exelon patch 9.5 mg/24 hr

Namenda 5 mg BID

Lantus 10 units at HS

Novolin R sliding scale PRN (scale not documented on transfer records)

Calcium supplement (dose not documented on transfer records)

Vitals:

Height: 5’2” Weight: 136 pounds

BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2/14:

Na (mEq/L) = 138 (135 – 145)

K (mEq/L) = 3.6 (3.5 – 5)

Cl (mEq/L) = 100 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 20 (7 – 20)

SCr (mg/dL) = 1.1 (0.6 – 1.3)

Glucose (mg/dL) = 187 (100 – 125)

Ca (mg/dL) = 8.7 (8.5 – 10.5)

Mg (mEq/L) = 1.3 (1.3 – 2.1)

PO4 (mg/dL) = 2.2 (2.3 – 4.7)

A1C (%) = 8.9

Albumin (g/dL) = 3.6 (3.5 – 5)

Labs on Hospital Admission 12/15/14:

Na (mEq/L) = 135 (135 – 145)

K (mEq/L) = 3.1 (3.5 – 5)

Cl (mEq/L) = 99 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 42 (7 – 20)

SCr (mg/dL) = 1.4 (0.6 – 1.3)

Glucose (mg/dL) = 169 (100 – 125)

Ca (mg/dL) = 8.8 (8.5 – 10.5)

Mg (mEq/L) = 1.0 (1.3 – 2.1)

PO4 (mg/dL) = 1.9 (2.3 – 4.7)

A1C (%) = 8.8

Albumin (g/dL) = 2.9 (3.5 – 5)

Tests:

EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending.

Question:

An order is placed for LS to receive 40 mEq of KCl IV with continuous EKG monitoring. The hospital stocks premixed bags of 20 mEq KCl/100 mL 0.9% NaCl. The pharmacist modifies the order to read “20 mEq KCl/100 mL 0.9% NaCl x 2 doses.” Over what period of time should each 20 mEq KCl bag be infused?

Answer

A1-2 minutes

B30 minutes

C2 hours

D6 hours

E12 hours

Back 29

C2 hours

Front 30

An ICU patient with severe renal impairment requires a neuromuscular blocking agent (NMBA) in order to receive mechanical ventilation. Which of the following statements are correct? (Select ALL that apply.)

Answer

AThe medical staff must ensure that the patient is adequately sedated prior to the use of the NMBA.

BThe medical staff must ensure that the patient is receiving appropriate analgesia prior to the use of the NMBA.

CSuccinylcholine binds to the GABA receptor, resulting in activation.

DICU sedative agents are monitored via a nerve stimulator.

EPatients must be mechanically ventilated prior to receiving a NMBA or they will suffocate; they should also be administered eye lubricant.

Back 30

AThe medical staff must ensure that the patient is adequately sedated prior to the use of the NMBA.

BThe medical staff must ensure that the patient is receiving appropriate analgesia prior to the use of the NMBA.

EPatients must be mechanically ventilated prior to receiving a NMBA or they will suffocate; they should also be administered eye lubricant.

Front 31

A patient's norepinephrine intravenous line extravasated into the surrounding tissue. The nurse quickly starts to give phentolamine to reverse any skin necrosis. What is the mechanism of action of phentolamine?

Answer

AAlpha-adrenergic antagonist

BAlpha-adrenergic agonist

CBeta-adrenergic antagonist

DBeta-adrenergic agonist

ECalcium channel antagonist

Back 31

AAlpha-adrenergic antagonist

Front 32

Sam presented to the ED with severe dehydration. He was out hiking in the Arizona sun and forgot to bring water. He got lost and a 1 hour hike turned into a 6 hour hike. He is lethargic and nauseous. The Chem-7 just came back and his serum sodium level is 128. He has no evidence of seizure activity presently. Which of the following represents the best initial therapeutic option to correct Sam's sodium?

Answer

AConivaptan

B3% NaCl

CD5W

D0.9% NaCl

EHydroxyethyl starch

Back 32

D0.9% NaCl

Front 33

A pharmacist is preparing an IVIG infusion. Which of the following statements is incorrect?

Answer

AIf the patient experiences side effects such as nausea or a drop in blood pressure during the infusion, slowing the infusion rate may be helpful.

BIVIG may come already in solution, or it may come as a powder that is reconstituted with diluent.

CThe IVIG dose is based on the Ideal Body Weight (IBW).

DIf particles are present, the pharmacist should shake well to dissolve the particles prior to the infusion.

ECertain patients respond to one IVIG brand better than another.

Back 33

DIf particles are present, the pharmacist should shake well to dissolve the particles prior to the infusion.

Front 34

A patient is in the OR and has received succinylcholine for intubation and is currently receiving inhaled isoflurane (an inhaled anesthetic) during surgery. The rare, but serious side effect this patient is potentially at risk for is:

Answer

ANeuroleptic malignant syndrome

BSundowning effect

CSerotonin syndrome

DMalignant hyperthermia

EAcute quadriplegic myopathy syndrome

Back 34

DMalignant hyperthermia

Front 35

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.

Allergies: NKDA

Medications:

Norvasc 10 mg PO daily

Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)

Exelon patch 9.5 mg/24 hr

Namenda 5 mg BID

Lantus 10 units at HS

Novolin R sliding scale PRN (scale not documented on transfer records)

Calcium supplement (dose not documented on transfer records)

Vitals:

Height: 5’2” Weight: 136 pounds

BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10

Labs from Nursing Home on 10/2/14:

Na (mEq/L) = 138 (135 – 145)

K (mEq/L) = 3.6 (3.5 – 5)

Cl (mEq/L) = 100 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 20 (7 – 20)

SCr (mg/dL) = 1.1 (0.6 – 1.3)

Glucose (mg/dL) = 187 (100 – 125)

Ca (mg/dL) = 8.7 (8.5 – 10.5)

Mg (mEq/L) = 1.3 (1.3 – 2.1)

PO4 (mg/dL) = 2.2 (2.3 – 4.7)

A1C (%) = 8.9

Albumin (g/dL) = 3.6 (3.5 – 5)

Labs on Hospital Admission 12/15/14:

Na (mEq/L) = 135 (135 – 145)

K (mEq/L) = 3.1 (3.5 – 5)

Cl (mEq/L) = 99 (95 – 103)

HCO3 (mEq/L) = 27 (24 – 30)

BUN (mg/dL) = 42 (7 – 20)

SCr (mg/dL) = 1.4 (0.6 – 1.3)

Glucose (mg/dL) = 169 (100 – 125)

Ca (mg/dL) = 8.8 (8.5 – 10.5)

Mg (mEq/L) = 1.0 (1.3 – 2.1)

PO4 (mg/dL) = 1.9 (2.3 – 4.7)

A1C (%) = 8.8

Albumin (g/dL) = 2.9 (3.5 – 5)

Tests:

EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval

Urinalysis and blood cultures are ordered and results are pending.

Question:

A dopamine drip is ordered for LS. Which of the following represents the correct combination of dose-effect relationships for dopamine?

Answer

ALow dose → vasopressor effects, medium dose → positive inotropic effect, and high dose → renal vasodilation

BLow dose → positive inotropic effect, medium dose → renal vasodilation, and high dose → vasopressor effects

CLow dose → vasopressor effects, medium dose → renal vasodilation, and high dose → positive inotropic effect

DLow dose → positive inotropic effect, medium dose → vasopressor effects, and high dose → renal vasodilation

ELow dose → renal vasodilation, medium dose → positive inotropic effect, and high dose → vasopressor effects

Back 35

ELow dose → renal vasodilation, medium dose → positive inotropic effect, and high dose → vasopressor effects

Front 36

Which of the following drugs comes formulated in a lipid emulsion?

Answer

APrecedex

BValium

CFentanyl

DDiprivan

EAtivan

Back 36

DDiprivan

Front 37

A patient has been receiving 4 days worth of propofol for sedation post-traumatic brain injury. Which of the following statements regarding propofol are correct? (Select ALL that apply.)

Answer

AHypotension, apnea and elevated triglycerides are likely side effects.

BThis patient may be at risk for developing infections.

CThis medication can cause orange/red urine in rare cases.

DThis agent is generally shorter-acting than lorazepam.

EPropofol contains significant calories that must be account for in the daily nutrition plan for the patient.

Back 37

AHypotension, apnea and elevated triglycerides are likely side effects.

BThis patient may be at risk for developing infections.

DThis agent is generally shorter-acting than lorazepam.

EPropofol contains significant calories that must be account for in the daily nutrition plan for the patient.

Front 38

Which of the following agents is a depolarizing neuromuscular blocking agent?

Answer

ASuccinylcholine

BCisatracurium

CPancuronium

DVecuronium

EAtracurium

Back 38

ASuccinylcholine

Front 39

A pharmacist receives an order for Diprivan. Which of the following is an appropriate generic substitution for Diprivan?

Answer

APropofol

BDiltiazem

COxycodone

DLorazepam

EPropantheline

Back 39

APropofol

Front 40

What are the risks associated with providing intravenous H2RA or PPI therapy to patients who do not require stress ulcer prophylaxis? (Select ALL that apply.)

Answer

AIncreased infection risk by increasing gastric pH and allowing bacteria overgrowth in the GI tract and airways.

BIncreased risk of contracting hospital-acquired pneumonia.

CIncreased risk of developing Clostridium difficile diarrhea.

DIncreased risk of GI bleeding.

EIncreased risk of VTE.

Back 40

AIncreased infection risk by increasing gastric pH and allowing bacteria overgrowth in the GI tract and airways.

BIncreased risk of contracting hospital-acquired pneumonia.

CIncreased risk of developing Clostridium difficile diarrhea.

Front 41

Ana has recently been admitted to the intensive care unit after an acute asthma exacerbation. She has been intubated and requires adequate sedation. She has normal renal and liver function. The medical team wants to use the shortest acting benzodiazepine available intravenously for sedation. Which of the following medications would be the best recommendation for Ana?

Answer

ATemazepam

BLorazepam

CDiazepam

DClonazepam

EMidazolam

Back 41

EMidazolam

Front 42

A patient is receiving vecuronium for paralysis. Which of the following medications can potentiate the actions of vecuronium?

Answer

ATricyclic antidepressants

BAngiotensin converting enzyme inhibitors

CProton pump inhibitors

DAminoglycosides

EAzole antifungals

Back 42

DAminoglycosides

Front 43

Nina is a 32 year-old female who is in the coronary care unit after a sudden drop in blood pressure following her cardiac catheterization procedure earlier this morning. Her blood pressure remained stable for the past two hours without the use of medications. She is sitting up in bed and eating her lunch. The medical team is anticipating sending her home by this evening or early tomorrow morning. Is Nina a candidate for stress ulcer prophylaxis?

Answer

AYes, since she is in the coronary care unit.

BYes, since she has had a stressful event.

CNo, since she does not have any risk factors.

DNo, since she is sitting up in bed.

EThere is not enough information given.

Back 43

CNo, since she does not have any risk factors.

Front 44

An ICU patient is receiving dexmedetomidine for sedation. Which of the following statements regarding dexmedetomidine is incorrect:

Answer

AThe duration of the infusion should not exceed 72 hours.

BThis agent has a very low risk of causing respiratory depression.

CPatients are arousable and alert upon stimulation when using this agent.

DThe BP and HR must be monitored.

EDexmedetomidine can cause significant blood pressure changes upon initiation of the infusion.

Back 44

AThe duration of the infusion should not exceed 72 hours.