You have a patient with severe aortic stenosis. What medication should be avoided or used with caution?
because the patient with aortic stenosis is sensitive to preload since their ability to augment their SVR is limited
Stage A B C D of heart failure
(this is NOT the NYHA classification)
A: risk factrors for HF but NO signs or symptoms
B: no symptoms (asymptomatic), but signs (LVH, S4)
D: patients with refractory symptoms. require therapy like IABP
A patient with stage C of systolic HF, which medications would you avoid?
calcium channel blocker because they can be a negative inotrope
3 Drugs for HF
beta blockers (despite negative inotrope, improve outcomes)
signs/symptoms HF but normal EF and normal valves
lower extremity edema and weight gain are common in D HF patients
A patient with HF, EF 35%, unable to tolerate ACE I & ARB.
What is indicated?
beta blocker (improves survivial among pts with HF)
hydralazine and isosorbide dinitrate (replaces the ACE I/ARB)
*all three of them
CXR with kerly B lines, cephalization is indicative of:
HF (cephalization is increase prominence of vessels)
Syncopal patient presents with a harsh III/VI systolic murmur that radiates to the carotids
*aortic stenosis is r/t syncope, mitral is not
A patient has a-fib, DIASTOLIC low pitched murmur that radiates to the AXILLA, m-shaped p-waves. What is the murmur?
*the messed up AV valve leads to the a-fib and
A systolic murmur that radiates to the axillla
An HIV patient has signs/symptoms of HF, global hypokonesis, elevated cardiac enzymes, no valvular defects. What is the diagnosis?
*myocarditis is thought to have some autoimmune component
What medications are CONRAindicated in the INITIAL treatment of pericarditis?
steroids are INITIALLY avoided because they are thought to increase the chance of reoccurance AND increase risk of infection
An xray with a water bagged shaped heart is consistant with pericardial tamponade. Signs of tampondade are
equalization of hemodynamic pressures during diastole
decreased ECG voltage
A patient with metastatic cancer is at increased risk for pericardial ______ which can lead to cardiac tamponade. This patient may have distant heart sounds and JVD.
*get an echo to see tamponade/effusion!
You have established a dx of HTN in a patient with a heart transplant. What is the first drug of choice for this patient?
*first line HTN for heart transplant
Patient with large anterior lateral MI who doesn't respond to fluid and levo with BP 80/40, CI of 1.8, what med do you give next?
because their index is low
*not epi bc it increases myocardial 02 demand in MI and you don't want to do that
The AHA guideline for STEMI says ALL patients with STEMI should go home on _____ and have therapeutic lifestyle changes regardless of their lipid panel.
low dose statin and therapeutic lifestyle changes
Contraindicatoins for fibrinolytics in STEMI include
ischemic CVA less than 3 months ago
CHADS2 for patients with AFIB takes into account what and how many points do you need to get started on coumadin?
Age >= 75
Stroke/TIA/TE gets TWO points
*If you have CHADS2 score 2 or greater you start coumadin
According to JNC 7 guidelines, what is the goal BP for a patient with DM?
(normal pt <140/80 but bc JNC 7 with DM <130/80)
A patient with normal lipid panel EXCEPT elevated triglycerides, what medication would you give?
niacin (nicotinic acid) and fibrates are the drug of choice for high triglycerides
What medication is giving for peripheral arterial disease if claudication is treated medically?
This medication must be taken for weeks before results are scene.
How long should a post-op hip patient who is 85 with renal insufficiency be on DVT prophylaxis post op?
A shunt is perfusion without adequate ventilation. Blood is passing through the lungs, but isn't exposed to the alvioi. Examples are:
When there is a true shunt, no matter how much FIO2 you give them they won't respond because there isn't alvioli connecting to the blood
If the patient responds quickly to supplemental o2 is it a shunt or a ventilation-perfusion mismatch?
VQ mismatch because they responsd quickly to O2
Dead space example is PE. There IS ventilation, but there is no_____.
Enteral feeding recommendations for a patient with resp failure is:
calorie dense formula because this may help avoid fluid overload
On the test, if you are concerned about the risk of ventilator induced lung injury in a patient who is not assisting with breathing is:
PRESSURE control ventilation
A patient with interstitial lung disease (the area surrounding the alveoli is a problem so it is obstructive). What would you guess their PFTs to be?
interstitial lung disease is obstructive with a restrictive ventilitory pattern so:
high fev1/fvc ratio
Prior to performing a thoracentesis, what film should be obtained?
A patient with a positive silhoette sign at the L heart border. You are concerned that the patient has a infiltrate in which lobe?
The best view for a CXR is the _____ view?
this is with your chest toward the plate, radiation is coming from behind so the exposure goes from posterior to anterior
The NP using knowledge and expertise to integrate evidence based guidlines into formulating a plan of care is
Sytems thinking is driven by
strengths of families
strengths/weaknesses of staff
navigates the whole system
(blends with clinical judgement)
adapts standards of care to specific patients
questions current practice
maintains knowledge and skills
The focus of the ACNP practice is
providing restorative care
ACNP scope of practice
determined by the area of focus and identified needs of the patient
An important leadership activity of the ACNP is
interpreting the ACNP role to providers and the public
What is a nonreimbursable condition in the hospital according to medicare and medicaid?
central line infections
foreign body after surgery
stage 3-4 pressurre ulcers obtained in hospital
DVT after ortho surgery
On this test, based on UPSTF recommendations mamograms for women LESS than age 50
screening for women under age 50 depends on personal risk factors and personal choice
On this test a mamogram should be done from age 50-75 every other
UPSTF recommendation for colorectal cancer begins at what age?
start 50-75 end
can use fecal occult, sigmoidoscopy, colonoscopy
a high hiber diet helps prevent colorectal cancer
If you have a choice of interviewing the patient choose the question that starts with
When the patients written directive and the family don't agree what do you do?
get a third party involved (get the ethics committee)
Current evidence based practice states the most common gateway drug to subsequent illicit drug use is
nonprescription use of pain medicaiton
To determine the patients cr cl based on COCKFOFT GAULT eqaution
what is normal creatinine clearance?
cockroft gault equation to eval renal function
((140-age)xkg)/(plasma cr x72)
*if a girl x by 0.85
Patient with PO KCL overdose, not symptomatic, what is the treatment?
kayexalate bc prevents absorption in the gut and patient not symptomatic
Renal failure patient with elevated phos level. What is the drug of choice as a phos binder?
REpeated (chronic with repeated events = treatment failure) prostatitis/urosepsis. How long for abx?
4 to 12 weeks
UPSTF recommendation for PSA screening for prostate screening?
never at any age to risks outweight benefits
flomax is what drug class?
The most common cause of vaginal bleeding in postmenopausal women is
it is ruled out with endometrial biopsy
Pain, prutitis, palpable lesion on labia minora, and hyperpigmentation
cancer of the vulva
high incidence in women 80+ years old
A patient with a CABG and a surgical prolonged pump time who is bleeding with normal PT PTT and platelet counts.
check bleeding time or platelet function assay
*extended pump time messes up the platelet function
What abnormal labs are found in tumor lysis syndrome?
What type of transplant meds cause severe insomnia and mood swings?
HIV positive results
Western blot + with p24 and gp120