Question #3

Laura is a 42-year-old with a past medical history of liver transplant (2023) related to non-alcoholic steatohepatitis cirrhosis. She was admitted to the ICU after developing staphylococcus aureus pneumonia. During the day she had progressively worsening dyspnea and has been on high-flow nasal cannula at 60 LPM and 100% FiO2. During your initial shift assessment, you note the following findings:

• HR = 129 bpm, RR = 36 bpm, BP = 92/45 (61) mmHg, SPO2 = 91%, T = 38.1 C

• Laura is using her accessory and abdominal muscles to breathe and desaturates to 87-89% when she coughs

• She has a frequent, wet sounding cough, and she is producing thick, yellow sputum with traces of blood

• On auscultation you note coarse crackles and diminished sounds in all lobes (anterior and posterior) 

• She tells you, “I’m exhausted, I don’t think I can do this anymore”

You report your findings and Laura’s exhaustion to the provider, and they order an arterial blood gas with lactate and a chest X-Ray. They also ask you to calculate Laura’s P/F ratio. Your ABG shows the following:

• pH = 7.12, PaCO2 = 62 mmHg, PaO2 = 54 mmHg, HCO3 = 14 mEq/L, SaO2 = 88%, Lactate = 6.1 mmol/L

Interpret this ABG and calculate the P/F ratio. 

Provide a short rationale for why the provider might ask you to prepare Laura for intubation based on your assessment findings and interpretation of Laura’s ABG and P/F ratio. 

What nursing interventions do you expect after intubation? Select all that apply (you do not need to provide a rationale).

• A. Targeted sedation and pain management – this will allow Laura to rest comfortably on the ventilator and prevent ventilator desynchrony

• B. Q1H suctioning – this will clear Laura’s thick secretions and improve her respiratory status

• C. Prone positioning – this will improve Laura’s condition by allowing posterior alveoli to open which will increase oxygenation and improve ventilation/perfusion mismatch allowing for enhanced gas exchange

• D. Placement of a post-pyloric feeding tube and starting enteral nutrition to promote immune function and counteract the metabolic response to stress

Question #4

Alphee is a 62-year-old, unwell and distressed appearing male who presented to the emergency department with chief complaints of not feeling well in general for the past month, occasional shortness of breath and chest discomfort, subjective fevers and chills, unintentional weight loss, decreased appetite and night sweats (Figure 1). He has had chronic productive cough but for the past week, he noticed to have slightly pink phlegm upon expectoration. Upon lung auscultation, you noticed both mild inspiratory and expiratory wheezing. Alphee is originally from the Philippines and is just visiting the US in the next three months. Alphee also disclosed that he is a smoker, has history of alcohol abuse and multiple sexual partners but he is in the process of modifying his lifestyle now. Vitals taken and recorded as follows: T= 100.6 F, BP 140/70 mmHg, PR= 90 bpm, RR= 26 cpm, O2 Sat= 93% on room air. 

As the triage RN, based on Alphee’s risk factors and clinical manifestations, you have a high suspicion for him to have what kind of respiratory condition? What would be your consideration when rooming this patient and what would be the expected course of treatment and disposition for this patient?

Question #8

Jenny, a 24-year-old female, presents to her primary care office, with her partner, for a follow up appointment. For the past year, she has been reporting increased fatigue, dizziness upon standing and with prolonged standing, intermittent chest pain, exercise intolerance, headaches, abdominal pain, nausea, anxiety, and heat intolerance. Jenny’s initial VS (done while Jenny is laying down), PMH, and medications are listed in the table, in addition to the results of all the medical testing she’s had done. After getting Jenny’s VS, her nurse also gets standing VS. After 10 standing for 10 minutes, Jenny’s HR is 130 pm and her BP is 108/74. Jenny reports that while standing she began experiencing mild dizziness, headache, nausea, and mild chest pain. At this point, Jenny’s partner states, “Jenny, with how much salt you eat, I don’t know how your blood pressure isn’t sky high.” 

What condition is most likely causing Jenny’s symptoms? What test is used to diagnose this condition? What are 3 points lifestyle modifications that Jenny can make to help manage her symptoms (please also give a short 1-2 sentence rationale for the lifestyle modification)? 

Bonus: Briefly describe one of the physiological mechanisms that may be responsible for Jenny’s symptoms.

Question #9

A 30 yr olds pregnant 20-week gestation patient is seen for a routine anatomy scan. Pregnancy thus far has been typical without any major concerns. The ultrasound results are sent to the provider for review, the finding are as follows. Ventricular septal defect (VSD) and aortic septal override noted in the findings. 

• 1. What diagnosis do you suspect the fetus to have? And what other test can you anticipate making a referral for, to confirm diagnosis? 

• 2. Once the newborn is delivered what clinical manifestation do you expect to see in the baby? 

• 3. What therapies do you anticipate the newborn will need? 

Question #10

Peter is a 46-year-old man who presents to the Emergency Department (ED) with extreme emotional distress, agitation, and suicidal ideation. Incidentally, on admission, this patient also had a fever, a new murmur, fatigue, and an increased oxygen demand, needing 4L to stay above 92% on SpO2. Due to the high safety risk, this patient was assigned a continuous observer (CO), and his belongings were searched, which showed drug paraphernalia, notably syringes and a peculiar dark brown liquid substance in a small container. The belongings were confiscated, and the appropriate items were stored in a locker. Later in that shift, the patient was allowed to use a hospital phone to call a friend, and his CO noticed that when he was pacing in his room on the phone, he was getting increasingly short of breath before sitting down. As he sat down and finished his call, the patient became irate. He expressed out of anger and frustration that the brown liquid was indeed heroin. His friend had just found out through other contacts that the heroin he had been regularly supplied with was laced/diluted with the liquid from wet dog food. 

This information was relayed to the doctor, and blood cultures, CBC, and BMP were drawn, and diagnostic imaging was completed. One of the diagnostic imaging procedures was a transesophageal echocardiogram (TTE) (results shown in the image).  Based on the image, what would you say Peter’s diagnosis is?  What kind of medication would you expect this patient to receive to treat this diagnosis? Name at least three associated complications you may want to watch out for. While not required in your answer for this question, think of what these complications may look like on presentation and your response.

Question #11

You are assigned to care for a patient admitted for sepsis. After being admitted to the hospital for the last few days, this patient is now afebrile, with stable vital signs, is on IV antibiotics with a down-trending WBC, and is stable overall. You go into this patient’s room, take their routine vital signs for the night, and notice that their heart rate is now jumping between 110-150s inconsistently on the vital sign machine. They do not complain of dizziness, chest pain, or heart palpitations. You notify the provider, and they ask you to get an ECG/EKG showing the following rhythm. 

What heart rhythm does this patient have? 

The provider wants you to give a beta blocker to convert this patient out of this rhythm. Name a beta blocker medication that you could give this patient and what education you would provide to the patient about how this medication will help treat their abnormal rhythm. 

Lastly, you learn that this patient has a history of converting into this rhythm. Discuss at least 2 points of education you would give to the patient to manage this rhythm at home. 

Question #12

John, a 70-year-old male, came to ED with his son, reports feel tight to his chest, toothache, and sweating. The system started an hours ago while he was walking outside to pick up the mails. He has a history of 20 years oof smoking, but quit smoking 30 years ago, hypertension and hyperlipidemia. V/T: 97.8F, HR 100, RR 21, SPO2 94%, BP 150/96. EKG show on right

Question: 

• 1. What does EKG show?

• 2. What Labs would you recommend? List at least 3.

• 3. Based on the case scenario and EKG, what diagnosis would you suspect? Write a short summary to describe this diagnosis.

• 4. What treatments should be initiated?  List at least 2 medications and 2 treatments

Question #15

You are a nurse in the Emergency Department. A 4-year-old male is brought in by his parents with a chief complaint of a persistent fever lasting for five days with his temperature ranging from 101°F (38.3°C) to 104°F (40°C) that has been unresponsive to antipyretics. The parents report that the patient has had poor appetite, irritability, and loss of interest in playing with his siblings. Upon physical examination, you note the following:

• Eyes: Bilateral bulbar conjunctivitis without discharge

• Mouth: swollen, bumpy, red tongue (“Strawberry tongue”)

• Skin: a diffuse, red rash on the patient’s back

• Extremities: Swollen hands 

1. What is the patient’s most likely diagnosis? Please support your answer with the patient’s clinical presentation.

2. What medication(s), considered as the treatment of choice, would you expect to be included in the treatment plan of this patient? What education might you provide for the patient’s family related to this/these medication(s)? Please list at least two examples of educational points to share with the patient’s parents/family.

Question #17

A 45-year-old female presents to your emergency department reporting left jaw pain, neck pain, throbbing left-sided headache, a feeling of being on a roller coaster, and some double vision for the past 24 hours. She recently went to the chiropractor for neck pain sustained from injuries from a car accident six months ago. Her blood pressure is 160/100, HR 85, RR 15, Temp 36.5, 99% on RA.

Explain what you are concerned she may be experiencing, what physical assessments you would perform, and what imaging orders you would anticipate.

BONUS: What is she at extreme risk with this condition? 

Question #18

You are a nurse working on a post-surgical unit. Your patient, Ron, is a 52-year-old male who is 3 days post abdominal surgery for treatment of metastatic colon cancer, on strict bedrest. Upon assessment, you note that the Ron’s right leg is warm, red, and swollen from the calf to the mid-thigh. Ron reports a throbbing pain in his right leg, rated a 6/10. His vital signs are stable. Ron also has a history of Type 2 Diabetes and formerly smoked ½ pack/day for 15 years. A doppler ultrasound confirms that Ron has a proximal right lower extremity deep vein thrombosis (DVT). 

• 1) What contributing factors may have led Ron to develop a DVT? Identify two factors.

• 2) Based on this clinical finding, what would be the most appropriate initial pharmacological treatment for this patient (assuming that Ron is determined not to be experiencing an active bleed post-surgery)? Name one medication that may be indicated and briefly explain why.

• 3) Name and briefly explain one complication that can arise if this DVT went unnoticed or untreated.

Question #20

Robert, a 67-year-old man, arrives at the emergency room with mild abdominal pain and swelling in his lower extremities that has been worsening over the past two weeks. He denies having a fever, a worsening cough, or producing a lot of phlegm. He denies having severe chest pain, although he does admit that he "gets breathless" more quickly than normal when climbing stairs. He has a medical history of hypertension, hyperlipidemia, and COPD, which was identified eight years ago. Despite receiving treatment, he still smokes a few cigarettes every day. He has hepatomegaly, bilateral pitting edema up to the knees, and jugular vein distention (JVD) on examination. There are slight expiratory wheezes and a reduction in breath sounds throughout. An X-ray of the chest reveals a flattened diaphragm and hyperinflated lungs without any acute infiltrates. His BNP is slightly elevated, and on room air, his oxygen saturation is 90%.

• 1. What are two key abnormal physical findings in Robert that suggest a complication beyond simple airflow obstruction?

• 2. Why is it important to differentiate whether Robert’s symptoms are primarily from COPD progression versus another cardiac cause?