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4EH PCCN Flashcards

1
Q

What does the renal system conserve on injury?

A

Water and sodium

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2
Q

What is the lag time on creatinine?

A

12 hours

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3
Q

What is fluid balance regulated by?

A

Aldosterone, thirst, ADH, ANP, RAAS

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4
Q

Aldosterone release is triggered by what?

A

Elevated K+ (to get rid of it)

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5
Q

AKI causes what

A 
Retention of metabolic waste (acidosis)
Fluid overload
Electrolyte imbalance (K, mag, and phos all increase)
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6
Q

Which medications can cause AKI

A

Vanco, gent, and antivirals

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7
Q

What is the normal BUN/Creatinine ratio?

A

10:1

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8
Q

GFR estimates what?

A

Creatinine clearance

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9
Q

What would you see in the urine with tubular distress?

A

Proteinuria

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10
Q

Normal creatinine clearance is what?

A

80-120 mL/min

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11
Q

Post-renal AKI may be caused by what

A

Urethral obstruction

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12
Q

Pre-renal AKi labs would look like

A

Conserve Na+ and H20, decreased UOP. Urine Na+ would be low 2/2 conservation of sodium in body

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13
Q

Pre-renal AKI results from

A

Hypoperfusion (Sepsis, HF, trauma, hypovolemia)

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14
Q

What would the BUN:Creatinine look like in pre-renal AKI

A

25:1 because BUN readily elevates, creatinine takes time

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15
Q

Renal protection bundle consists of what

A

Adequate HYDRATION
Adequate PERFUSION
Stop NEPHROTOXIC meds (i.e. vanc)

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16
Q

BUN:Creatinine in ATN

A

10:1 but BOTH ELEVATED

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17
Q

Management of ATN

A

Supportive tx
Permanent damage to tubules means pt will likely need HD
Prevent acidosis, electrolyte imbalance, and uremia

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18
Q

You would expect to see ___ in the urine of someone with ATN

A

Casts

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19
Q

Toxic ATN

A

**REVERSIBLE with early intervention
Caused by meds (vanco gent, antivirals)
Uniform, wide-spread damage
Can recover in 8 days

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20
Q

Ischemic ATN

A

Irregular damage along tubular membranes
Tubular cell damage and cast formation
Poor to no perfusion to kidneys
Long recovery with 50% mortality rate

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21
Q

Your patient is in the polyuria (diuretic) stage of ATN. Because of this you know you must monitor which lab?

A

Serum Potassium

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22
Q

3 phases of ATN

A

Oliguric phase, diuretic phase, recovery phase

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23
Q

Oliguric phase of ATN

A

Insult to injury within 48 hours
Decreased UOP
Increased metabolic waste
Electrolyte imbalance (K+, mag, phos)
High urine specific gravity 2/2 Na+ conservation
Decreased bicarb because pt becoming acidotic
Needs HD

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24
Q

Diuretic phase of ATN

A

Lasts 7-14 days
Wasting K+ and Na+ ->watch closely!
Gradual improvement of renal function
Urine specific gravity decreases
Monitor for fluid deficit, can cause re-injury
Still needs HD to get rid of waste but don’t take water off

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25
Recovery stage of ATN
Can progress to CKD | GFR returns to <80% within 1-2 years but will never be the same
26
Contrast induced nephropathy
Prevention and treatment: HYDRATION | Hydrate patients prior and after
27
Indications for Dialysis
``` AEIOU Acid/base imbalance (acidosis) Electrolyte imbalance (kyperkalemia, mag, phos) Intoxications (ODs/toxins like tylenol) Overload- fluid Uremic symptoms (climbing creatinine) ```
28
Calcium and phosphate have a(n) _____ relationship
Inverse
29
What labs are associated with kidney injury (acute or chronic)?
Decreased calcium, increased K, increased creatinine
30
A patient with chronic renal failure has a Hgb of 7 mg/dL, BUN 38, creatinine 3.2, K+ 4.6. You should anticipate administration of which of the following? Kayexelate Calcium gluconate Epoetin alpha Mag Sulfate
Epoetin alpha to stimulate RBC production
31
CKD labs
Anemia** Increased BUN/creatinine/PO4 Decreased Ca++, HCO3, protein
32
Top 2 risk factors for CKD
DM and HTN (responsible for 70% of CKD cases)
33
Your patient is scheduled for HD today at 11 am. You have several 9am meds. You should: Administer all the meds Hold all AM meds until after dialysis Decide which meds are affected by dialysis and adjust as needed Give only cardiac meds
Decide which meds are affected by dialysis and adjust as needed
34
Meds removed by HD
BLIST MED Barbiturates, lithium, isoniazid, salicylates, theophylline/caffeine, methanol, ethelyene glycol, depakote Hold all BP meds until after HD!
35
One of the most common complications of intermittent HD is: Hypokalemia Hypotension Chest Pain Anemia
All are possible but HYPOTENSION is the most common because you're displacing blood
36
HD was just initiated on your patient. The BP dropped from 178/64 to 116/52 and they feel lightheaded. Which would be the most appropriate action to take? Increase the ultrafiltration rate Start dobutamine infusion Give 500 mL fluid bolus Decrease the ultrafiltration rate
Decrease the ultrafiltration rate, essentially meaning slow down the removal rate
37
A 34 year old pt with AKI was dialyzed 1 hour ago. Now she is increasingly confused and agitated. The most likely cause of this is: Delerium Azotemia (increased nitrogen in blood) SAH Dialysis Disequilibrium Syndrome
Dialysis Disequilibrium Syndrome Usually self-resolving Wait for the urea nitrogen to equilibrate on both sides of the blood brain barrier
38
The main reason to utilize CRRT over intermittent HD is: Hemodynamic instability Severe anemia Fluid overload >10 L Severe hypokalemia
Hemodynamic instability
39
Venous Air Embolus
SOB, CP, acute R heart failure (looks like a PE) Treatment: lay on L side, trendelenburg. Hyperbaric with 100% FiO2 to accelerate the removal of nitrogen
40
Arterial Air Embolus
Change in LOC, decreased arterial flow/ perfusion (looks like stroke or clot) Treatment: High flow O2, L side trendelenburg
41
Which of the following lab values would you expect to see in a patient in the oliguric stage of ATN? (USG= urine specific gravity) USG 1.025, BUN/creat of 10:1, urine Na 8 USG 1.004, BUN/creat 10:1, urine Na 50 USG 1.004, BUN/creat 25:1, urine Na 50 USG 1.025, BUN/creat 25:1, urine Na 8
Last one USG 1.025, BUN/creat 25:1, urine Na 8 heavy urine, BUN:creat is 10:1 in ATN
42
Your pt who experienced AKU this hospitalization is being discharged. Which of the following medications should they be instructed to avoid? Opioids Tylenol NSAIDS ACE inhibitors
NSAIDS
43
Low electrolytes lead to acidosis or alkalosis?
Alkalosis LOW electrolytes= alkaLOsis Drop acid, get high
44
A 78 year old pt admitted with N/V and severe dehydration. Na is 152 mEq/L. You would expect to see the following lab profiles? Elevated urine specific gravity, elevated hemoglobin, decreased serum osmolality Elevated urine specific gravity, elevated Hgb, elevated serum osmolality Decreased urine specific gravity, elevated Hgb, decreased serum osmolality Decreased urine specific gravity, decreased Hgb, elevated serum osmolality
Second one Elevated urine specific gravity, elevated Hgb, elevated serum osmolality
45
We replace sodium ___ (quickly or slowly) because....
Slowly to prevent nerve demyelination (permanent)
46
Which of the following patients is at highest risk of developing hyperkalemia? GIB with administration of 3u PRBCs Severe vomiting and dehydration with administration of 4L LR HF pt on ACEi and Spironolactone Refeeding syndrome after being NPO for 5 days
HF pt on ACEi and Spironolactone, spironolactone is K+ sparing. ACEi alter ADH which alters K+ Vomiting and dehydration would have high Na+, GIB patient after 3u PRBCs would have high Calcium
47
Hyponatremia
Too much water or Na+ loss? Water retention or dehydration
48
Where is the primary excretory source for K+?
Kidneys
49
Development of a "u" wave on ECG is indicative of which of the following? Hypokalemia Hypermagnesemia Hypophosphatemia Hypercalcemia
Hypokalemia
50
Which of the following EKG changes would you expect with a pt with a potassium of 6.2? Prolonged PR interval Shortened QT interval Tall Peaked T waves Prominent U waves
Tall Peaked T waves
51
What are some causes of Hyperkalemia?
Renal failure, severe trauma and burns, DKA, rhabdo, infection, decreased CO, Acidosis
52
Emergent treatment of Hyperkalemia
Move potassium: Insulin , calcium chloride (cardio protective), sodium bicarb, albuterol Remove potassium: emergent dialysis, loop diuretics, kayexelate
53
Which electrolyte deficiency will produce torsades and is commonly associated with alcoholism? Potassium Calcium Mag Sodium
Mag
54
In a patient with a K of 2.9 and a mag of 1.1 with an arrythmia, which should be replaced first?
Mag
55
Signs of hypermagnesemia include the following: Tetany, rigid extremities Muscle weakness, lethargy Decreased deep tendon reflexes, tetany Lethargy, Torsades de pointes
Muscle weakness, lethargy High risk: renal pts, boosting from repletion, OB *mag drag with high mag
56
A 65 year old pt is admitted S/P cardiac arrest from the ED. His labs return and are as follows: K+: 4.7 , Mg++: 5.2, Na+: 148 The patient is hypotensive and extremely flaccid. Which of the following should you anticipate? Emergent HD Administer 1 amp of calcium gluconate IV Administer nebulized mucomyst Administer Kayexelate
Administer 1 amp of calcium gluconate IV, the antidote to increased mag
57
Hypermagnesemia
Rare Caused by renal failure, DKA, or acidosis vasodilation, flushing, hypotension Fluids and diuretics
58
Phos and calcium have a(n) ___ relationship
Inverse
59
Signs of hypocalcemia include: Tall peaked T waves on ECG Chvostek's sign ST depression Hepatojugular reflex sign
Chvostek's sign -> facial nerve twitching with twitching on face. Tall T waves is increased K+ ST depression is decreased K+ Hepatojugular reflex sign is R HF
60
You notice when assessing the BP of your renal failure patient their arm and hand muscles are in spasm. You suspect which of the following electrolyte imbalances? Hyperphosphatemia Hypercalcemia Hyperkalemia Hypermagnesemia
Hyperphosphatemia -> Trosseau's sign is low Ca++ or high phos
61
How does hypocalcemia affect the respiratory system
Bronchospasm, labored, shallow breathing
62
The following ABG is most likely associated with: pH 7.51, pCO2 35, pO2 188, HCO3 35 Hyperchloremia Hyperkalemia Hypercalcemia Hypochloremia
Hypochloremia Metabolic alkalosis
63
Inotrope vs chronotrope
Inotropes effect contractility +inotropic improve, - decrease Chronotropic effect heart rate + increase HR, - decreases
64
AV valves (mitral and tricuspid) open during
Diastole and closed during systole
65
Semilunar valves (Aortic and pulmonic) valves are open during
Systole and closed during diastole
66
Posterior wall of the heart is perfused by
90% RCA and 10% CRFX
67
Circumflex artery perfuses...
Lateral wall of L ventricle, L atrium, back of L ventricle
68
LAD perfuses...
Septal and anterior wall of heart, front and bottom wall of L ventricle, and front of septum
69
RCA perfuses...
Inferior wall of the heart, R atrium, SA node, AV node, R ventricle, back of the septum
70
Preload
initial stretching of myocardium prior to contraction, therefore related to sarcomere length at the end of diastole
71
Afterload
Resistance the ventricle has to overcome to eject blood High afterload= vasoconstriction (HTN)
72
Split heart sounds are best heard during
Inspiration
73
Isotonic IV fluids
Volume expanders, stay in vasculature
74
Hypertonic IV fluids
Shift from cell to vasculature
75
Hypotonic IV fluids
Shift from vasculature to cell
76
A patient presents with AMS and tachypnea. ABG results: pH 7.25, PaCO2 28, PaO2 9-, HCO3 18 Ketones are present in the serum and urine, serum osmo is 320, serum sodium 130, anion gap is 22. Based on these lab findings, you suspect the following diagnosis: HHS DKA DI Adrenal crisis
DKA, metabolic acidosis
77
Clinical manifestations of DKA include: Hyperglycemia, hypo-osmolality, and anion gap acidosis Hyperglycemia, hyper-osmolality, and hypernatremia Hyperglycemia, hypo-osmolality, and ketone production Hyperglycemia, hyper-osmolality, and anion gap acidosis
Last one | Hyperglycemia, hyper-osmolality, and anion gap acidosis
78
An 18 year old with DM1 is admitted with a hyperglycemia emergency. Her initial glucose was 520 mg/dL with a potassium of 6.2. Your priority when caring for her is: Correcting her glucose levels Lowering her potassium level Restarting her SQ insulin Correcting her fluid deficit
Correcting her fluid deficit
79
Anion gap normal
<11-12. Gap >12 is associated with metabolic acidosis
80
Four hours after starting on an insulin infusion in a patient with DKA, the pts blood glucose is 235 mg/dL. Which of the following fluids should be administered? Hypertonic solution to hydrate the cell D5 .45NS or D5NS with a glucose source Isotonic saline bolus to maintain extracellular hydration Hypotonic saline to provide cellular hydration
D5.45NS or D5NS with a glucose source
81
Insulin management in DKA
Overlap SQ insluin and insulin gtt by 2 hours, goal is to shut down ketone production
82
A cardinal sign of HHS is Ketones present in serum and urine with increased serum osmolality Decreased serum osmolality with rapid and shallow breathing Markedly elevated serum glucose and AMS Volume overload and metabolic acidosis
Markedly elevated serum glucose and AMS
83
HHS treatment
Add dextrose when glucose is 250-300 mg/dL to prevent hypoglycemia Pts are also 5-10L fluid down so can go into hypovolemic shock Type 2 DM
84
Nursing consideration with SIADH
Safety!! Fall and seizure precautions Correct Na+ slowly, prevent irreversible damage to neuron myelination
85
A common lab finding in a pt with DI is Decrease serum osmolality Decreased UOP Elevated urine specific gravity Elevated serum osmolality
Elevated serum osmolality
86
DI is caused by
Lack of ADH
87
You would expect which of the following lab findings in a pt with DI Increased serum osmo, decreased serum sodium, increased urine osmo Increased serum osmo, decreased urine osmo, increased serum sodium Decreased serum osmo, increased serum sodium, decreased urine osmo Decreased serum osmo, decreased serum sodium, decreased urine osmo
Second one Increased serum osmo, decreased urine osmo, increased serum sodium
88
56 year old pt S/P cardiac arrest and 45 mins of CPR. On day 2 of hospital stay you notice urine drainage bag is suddenly full. Urine is clear without color. Continues with UOP of 70-1000 mL per hour x2 hours. Which of the following assessment findings would you expect? Serum sodium level of 126 Serum osmolality of 320 Urine specific gravity of 1.025 Serum potassium of 3.5
Serum osmolality of 320
89
Pt from psych unit admitted for close monitoring after drinking 8 L of water in an hour. You would expect to find which of the following: Hyponatremia Hypernatremia Hypokalemia Elevated serum osmolality
Hyponatremia
90
A severely depressed diabetic patient is admitted after taking a large amount of insulin in an attempt to commit suicide. asking about suicidal thoughts and feelings will help you ascertain: If they have a specific plan to attempt suicide again Place the patient on suicide watch Give them ideas for successful suicide If they are more depressed
If they have a specific plan to attempt suicide again
91
You are caring for a pt who was admitted with an occluded VP shunt. Earliest signs of increased ICP include: Nystagmus Decreased LOC Slurred speech Unequal Pupils
Decreased LOC
92
How do you test cranial nerves: VII IX/X XI XII
VII: Smile IX/X: Swallow, gag, speech XI: Shrug shoulders XII: Stick out tongue
93
1 hour goal with stroke care
Assessment, CT scan, glucose NIHSS (higher score is worse) Treat with fibrinolytic therapy if needed
94
Which of the following patients is at highest risk for developing an embolic stroke? Atrial septal defect Supraventricular tachycardia second degree AV block type 1 Wolff-Parkinson-White Syndrome
Atrial Septal Defect
95
A pt is admitted with an acute ischemic stroke. After a head CT scan and assessment, there is high suspicion for embolic stroke. rtPA is ordered. The pt's BP is 220/160. Your initial priority is: Preparing for STAT administration fo rtPA Preparing for STAT cerebral angiogram Administer Mannitol IV to decrease cerebral edema Lowering pts BP to less than 185/110
Lowering BP to less than 185/110 YOU HAVE TO CONTROL BP PRIOR TO ADMINISTRATION
96
Window from last known normal to be able to give rtPA
4.5 hours 3 hour window if over 80, taking oral AC, hx stroke or DM, NIHSS score >25 baseline, or if CT reveals large injury (>1/3 of MCA territory)
97
Door to needle time for rtPA
Less than 60 mins
98
3 days after an embolic stroke, your pt is not able to swallow appropriately. Which of the following would be most appropriate to provide nutrition? Insert a central line to provide TPN Insert a small bore gastric tube to begin enteral feeding Arrange for radiology to insert a jejunostomy tube for enteral feedings Insert a PICC for parenteral nutiriton
Insert a small bore gastric tube and begin enteral feedings
99
Stroke care components (5)
Cardiac monitoring (A.fib, R/O ASD or PFO, ECHO if unexplained stoke) Airway support (O2 if sats less than 94%) TREAT HYPOGLYCEMIA BP target range AVOID FEVER! Don't treat fever, avoid it (associated with higher M/M)
100
46 year old with ruptured cerebral aneurysm will be placed on which of the following class of medication to prevent cerebral artery vasospasm? Beta blockers Angiotensin receptor blockers CCB ACEi
CCBs (i.e nicardipine x21 days)
101
Which of the following should be avoided in a patient with a basilar skull fracture? NG tubes Urinary catheters Fevers Central lines
NG tubes
102
Gold standard for diagnosing Epidural and subdural hematomas
CT scan
103
Complications associated with neuro insults (nursing considerations?)
Pulmonary complications i.e. airway protection and aspiration
104
You are admitting a pt S/P craniotomy for a ruptured aneurysm. Which of the following nursing actions should you anticipate? Administer Mannitol Q12 to reduce cerebral edema Position with HOB 30 degrees to optimize venous outflow Decrease MAP to improve CPP Monitor for delirium
Position with HOB at 30 to optimize venous outflow
105
Normal ICP
0-15 mm Hg Treatment indicated if sustained >20-25 mmHg
106
Ventriculostomy
Drain for hydrocephalus placed in lateral ventricle, can also use to monitor ICP
107
Management of a pt post SAH with increased ICP includes: Hypotonic saline, osmotic diuretics, and loop diuretics Beta blockers, hypertonic saline, and CCBs Optimal positioning, osmotic diuretics, and hypertonic saline CCBs, hypotonic saline, and anticonvulsants
Optimal positioning, osmotic diuretics, and hypertonic saline
108
Managing IICP
Positioning to manage venous drainage (30-45 degrees with good head alignment, straight legs, no stimuli) Normothermia (don't treat fever, avoid it) Assess for pain
109
Labs to monitor with mannitol
K+, osmo, and Na+
110
Foramen of Monro is at the level of the...
Tragus
111
In addition for figuring out the cause, priorities when caring for a patient experiencing a seizure include Safety and dilantin IV Monitoring for SIRS & preventing aspiration PNA Safety and administration of a benzo ICP monitoring and cerebral perfusion pressure optimization
Safety and give a benzo Dilantin takes a while to become therapeutic, ativan kicks in right away
112
Guillain-Barre
Autoimmune disorder AFTER A VIRAL INFECTION Ascending paralysis, concern for it reaching diaphragm. Can be unilateral or bilateral Treat with IVIG and plasmapheresis (albuminocytologic dissociation in CSF leading to damage to myelin sheath) Airway protection and respiratory failure
113
Seizure meds
Benzos (lorazepam is first line, can repeat in 5-10 mins) Diazepam (0.15 mg/kg IV repeat in 5 mins) Phenytoin/Dilantin (GIVE SLOWLY to avoid hypotension and bradycardia. load 10-15 mg/kg, peaks in 15-20 mins. Assess for infiltration @IV site)
114
Targeted temperature management
Target goal: 32-36 C for 24 hours to minimize reperfusion injury ->NEURO PROTECTIVE ONLY in patients remaining comatose after cardiac arrest Monitor for shivering, bradycardia, elevated lactate Slowly rewarm over 12-24 hours
115
Which of the following would be expected in a patient experiencing herniation and Cushing's Triad? Narrow pulse pressure, bradycardia, and hypotension Narrow pulse pressure, tachycardia, hypotension Wide pulse pressure, bradycardia, increased systolic pressure Wide pulse pressure, tachycardia, increased systolic pressure
Third one Wide pulse pressure, bradycardia, increased systolic pressure
116
Cushing's triad
Increased systolic BP (or widening pulse pressure) Decreased HR Decreased or irregular RR
117
A pt experienced a devastating ruptured basilar aneurysm. When preparing for brain death examination, you should expect which of the following findings? Absent oculocephalic reflexes and positive babinski sign Positive oculocephalic reflexes and blown pupils Absent oculocephalic and oculovestibular reflexes Decorticate posturing and pinpoint pupils
Absent oculocephalic and oculovestibular reflexes
118
Which cranial nerves do you assess for "dolls eyes"
III, VI, VIII Absent=brain dead Normal response= eyes turn with head turn
119
How do you test for an Oculovestibular reflex?
"Cold Calorics" Drop cold water into ear Normal response is to look towards stimuli Absent=brain dead Cranial nerves III, VI, VII
120
What is the only test someone with brain death will test positive for?
Apnea test (not breathing)
121
Kernig's sign
Inability to straighten leg when the hip is flexed 90 degrees. Associated with meningitis or SAH
122
Brudinski Sign
Severe neck stiffness; when neck flexed, causes knees to bend. Associated with meningitis and SAH
123
Normal PEtCO2 range (Capnography)
34-45 mmHg
124
A pt with an asthma exacerbation will exhibit which of the following physiologic signs? Decreased vital capacity, decreased peak inspiratory flow, decreased peak expiratory flow rate Increased vital capacity, decreased peak inspiratory flow, increased peak expiratory flow rate Decreased vital capacity, increased peak inspiratory flow, increased forced expiratory volume Increased vital capacity, decreased peak inspiratory flow, decreased forced expiratory volume
First one Decreased vital capacity, decreased peak inspiratory flow, decreased peak expiratory flow rate
125
You are caring for a pt with an acute episode of asthma exacerbation. The first line of treatment is Corticosteroids Beta2 agonist IV fluids CXR to rule out PNA
Beta 2 agonists aka albuterol to help with bronchodilation

4EH PCCN (1 decks)

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