ACLS 2022 229 QUESTIONS WITH COMPLETE SOLUTIONS, Exams of Nursing

Download ACLS 2022 229 QUESTIONS WITH COMPLETE SOLUTIONS and more Exams Nursing in PDF only on Docsity! ACLS 2022| 229 QUESTIONS| WITH COMPLETE SOLUTIONS Targeted temperature management - adults. correct answer: 32 - 36 C (89.6 - 95.2F). Titrate inspired O2 to... correct answer: the lowest level required to achieve arterial O2 sat 94% + to avoid complications associated with O2 toxicity. Mean arterial pressure goal correct answer: 65 mm Hg or greater A team leader should be able to explain why it is essential to... correct answer: push hard and fast in center of chest. ensure complete chest recoil. minimize interruptions in compressions. avoid excessive ventilation. A team member should be... correct answer: clear about role assignments. prepared to fill their responsibilities. well practiced in resuscitation. knowledgeable about algorithms. committed to success. Resuscitation triangle (3) correct answer: Compressor: assessed pt, 5 cycles chest compressions, alternates with AED person every 5 cycles or 2 min. AED/Defibrillator Monitor: brings and operates AED, places monitor where it can be seen by team leader, alternates with compressor every 5 cycles or 2 min. Airway: Opens airway, provides bag-mask ventilation, inserts airway adjuncts as appropriate. Leadership roles (3) correct answer: Team leader: every team needs one. assigns roles to team members, makes treatment decisions, provides feedback, assumes responsibility for roles not assigned. Meds: Initiates IV/IO access, administers meds. Time recorder: records time of interventions & medications and announces when next are due, records frequency and duration of interruptions in compressions, communicates to the team leader. Should you start CPR when you are unsure about a pulse? correct answer: Yes, unnecessary compressions are less harmful than failing to provide compressions when needed. Agonal gasps correct answer: A sign of cardiac arrest! May be present in first minutes. Looks like pt is drawing in air quickly. Occur at a slow rate. May be forceful or weak. Time passes between gasps. Snort, snore, groan. BLS assessment correct answer: Check responsiveness. Shout for help. Get AED/send someone. Look for breathing - chest 5-10 sec. Check pulse at same time. 5-10 sec. No pulse in 10 sec, start chest compressions. If pulse, rescue breathing 1 breath q 5-6 sec. Check pulse q 2 minutes. Defibrillation: check for shockable rhythm, shock, follow with compressions. Minimize interruptions correct answer: No longer than 10 sec! Avoid... prolonged rhythm analysis. frequent/inappropriate pulse checks. taking too long to give breaths. unnecessary moving the pt. Coronary Perfusion Pressure (CPP) correct answer: Aortic relaxation (diastolic) - right atrial relaxation (diastolic) pressure. Correlates with both myocardial blood flow and return of spontaneous circulation. ROSC does not occur unless it is 15 mm Hg or + If < 20 improve chest compressions and vasopressor therapy. Quality compressions correct answer: compress 2 in (5 cm). Rate 100-120 BPM. Allow complete recoil. single rescuer CPR correct answer: Cardiac arrest: Call for help, get AED, return to pt, start CPR. Hypoxia (drowning): give 2 mins CPR before activating emergency response system. Primary Assessment correct answer: Assess before action!!! Airway, Breathing, Circulation, Disability (Alert, Voice, Painful, Unresponsive), Exposure (remove clothing to examine). Secondary Assessment correct answer: Focused medical history and physical exam. SAMPLE Signs and sx. Holds tongue away from the posterior wall of pharynx. also used when suctioning intubated pts to prevent them from biting and occluding the ET tube. Too large or too small causes airway obstruction. OPA insertion correct answer: clear mouth/pharynx with suctioning. select proper size: flange is at corner of mouth, tip at mandible. Insert so it curves upward toward the hard palate. Insert at 90 or 180 degrees and turn. Nasopharyngeal Airway (NPA) correct answer: Used in pts who need a basic airway management adjunct. Soft rubber/plastic uncuffed tube that allows airflow between nares and pharynx. May be used in conscious, semi-conscious or unconscious pts. Indicated when OPA is technically difficult or dangerous (gag reflex, trismus, massive mouth trauma, wired jaws), neurologically impaired pts with poor pharyngeal tone/coordination. NPA Insertion correct answer: Select proper size: tip of nose to earlobe. (some providers use diameter of pt's smallest finger as a guide). Lubricate airway. Insert. If resistance: slightly rotate or attempt placement in other nares. ***Caution with facial trauma: risk of misplacement into the cranial cavity through a fractured cribriform plate. OPA and NPA precautions correct answer: Always check for spontaneous respirations immediately after insertion. Absent respirations: PPV. if no adjuncts available start mouth-to-mask barrier ventilation. Suctioning correct answer: Force of 80-120 mmHg. Soft catheters correct answer: used in the mouth or nose. Come in sterile wrappers and can be used for ET tube deep suctioning. Rigid catheters correct answer: Ex: Yankauer. Used in the oropharynx. Better for suctioning thick secretions. 3 EKG categories correct answer: ST segment elevation suggesting ongoing acute injury. ST segment depression suggesting ischemia. Nondiagnostic/normal EKG. Drugs to relieve ischemic discomfort, dissolve clots and inhibit thrombin/platlets correct answer: O2, aspirin, nitro, opiates (morphine), fibrinolytics, heparin. Additional: B-blockers, ADPs (clopridogrel, prasugrel, ticagrelor), ACEs, Statins, glycoprotein IIb/IIa inhibitors. Common causes of ACS deaths correct answer: VF or pulseless VT. ***VF likely to develop in first 4 hrs after sx onset. Priority in managing ACS correct answer: obtaining a 12 lead EKG. ***should be done in pt's first 10 min of arrival. Most common sx of myocardial ischemia and infarction correct answer: retrosternal chest discomfort. Also, pressure or tightness. Sx of ACS correct answer: uncomfortable pressure/fullness, squeezing pain in center of chest for several mins. chest discomfort spreading to shoulders, neck, arms, jaw, between shoulder blades. chest discomfort with light-headedness, dizziness, fainting, sweating, n/v. Unexplained SOB with or without chest discomfort. Other causes of chest discomfort correct answer: Aortic dissection. PE. Acute pericardial effusion with tamponade. Tension pneumo. When to administer O2 correct answer: Dyspneic, hypoxemic, obvious sx of HF, arterial sat < 90%, or sat is unknown. Titrate > 90%. When to administer Aspirin (Acetylsalicylic acid) correct answer: 160-325 mg non-enteric coated medication causes platelet inhibition. This reduces coronary reocclusion. Give: chew for better absorption (especially with morphine). Give rectally (300mg) if pt has GI bleed, n/v, PUD, upper GI disorders. Hold: allergy, has not taken med, no GI bleed. When to administer Nitroglycerin (Glyceryl Trinitrate) correct answer: Med reduces ischemic chest discomfort and causes reduction in LV and RV preload through peripheral arterial and venous dilation. 1 tablet or spray q3-5 min. Give: ONLY if stable. SBP > 90, HR 50-100. Hold: inadequate ventricular preload, RV infarction, hypoTN, brachycardia, tachycardia, with sildenafil or vardenafil within 24 hrs. Tadalafil 48 hrs. When to administer opiates (ex Morphine) correct answer: For chest discomfort unresponsive to nitro. CNS analgesia, produces venodilation --> decreases LV preload and O2 requirements, decreases systemic vascular resistance, helps redistribute blood flow. Give: STEMI. Caution: NSTEMI. Hold: preload dependent pts. Tx: fluids for hypoTN. When to administer NSAIDs correct answer: Contraindicated (except Aspirin) during a STEMI. Increased risk of mortality, reinfarction, HTN, HF, myocardial rupture. Tx goals for STEMI correct answer: Give fibrinolytics within 30 min or perform PCI (percutaneous coronary intervention) within 90 mins of arrival. First 10 minutes checklist correct answer: VS/O2. IV access. Brief focused hx and physical exam. Check for fibrinolytic contraindications. Obtain blood sample, eval cardiac markers, lytes and coagulation. Portable CXR. STEMI Category correct answer: ST elevation in 2+ leads or new LBBB. J-point elevation > 2mm in V2 and V3, 1mm+ in all other leads. ***2.5 males <40, 1.5 mm women. NSTE-ACS Category correct answer: Ischemic ST depression 0.5mm or greater/dynamic T- wave inversion with pain/discomfort. Nonperisenstent or transient ST elevation 0.5mm+ for < 20 min also. Low/Intermediate risk ACS Category correct answer: normal or nondiagnostic changes ST or T wave. ST deviation either direction of 0.5mm. T wave inversion < 2mm. Serial cardiac studies are appropriate (troponin). STEMI correct answer: Pt's usually have complete occlusion of an epicardial coronary artery. Tx is early reperfusion with PCI or Fibrinolytics in the first 12 hrs after onset of sx. ***Reperfusion saves heart muscle. Delay of therapy for STEMI - the 4Ds. correct answer: May occur from... Door to data (EKG) Sudden trouble seeing in one/both eyes. Sudden trouble walking. Dizziness/loss of coordination. Sudden severe headache with no known cause. Cincinnati Prehospital Stroke Scale (CPSS) correct answer: Facial droop, arm drift, abnormal speech. 1/3: 72% possibility. 3/3: 85+% possibility. Stroke EMS assessments correct answer: Check O2 for < 94% (if unknown, give O2). Perform CPSS. Determine time 0 (when pt was last known to be normal). Bring a witness if possible. Notify hospital of arrival. Check glucose during transport. Steps to take if there is no hemorrhage on CT and pt cannot have fibrinolytics. correct answer: Obtain swallow study (for safety swallowing) and administer Aspirin rectally or PO. Inclusion criteria for Ischemic Stroke correct answer: Correct diganosis. Onset of sx < 3 hrs. 18+ years old. Exlusion criteria for Ischemic Stroke correct answer: Head trauma in last 3 mo. Sx suggest subarachnoid hemorrhage. Arterial puncture in last 7 days. Hx of previous intracranial hemorrhage. BP 185/110 + Active internal bleeding. Platelets < 100k. Heparin in last 48 hrs. INR > 1.7. PT > 15 seconds. Blood glucose < 50. CT demonstrates multilobar infarction. Relative exclusion criteria for Ischemic Stroke correct answer: Minor or rapidly improving sx. Pregnancy. Seizure at onset. Major surgery or trauma within 14 days. Recent GI or urinary tract hemorrhage (21 days). Recent acute MI in past 3 mo. A typical CT scan 24hrs after starting fibrinolytics shows correct answer: no intracranial hemorrhage. Exclusion criteria for Ischemic Stroke 3-4.5 hrs after sx onset correct answer: 80+ years old. NIHSS Score > 25 (severe). PO anticoagulant (regardless of INR). Hx of both DM and prior stroke. Intra-arterial rtPA correct answer: for acute ischemic stroke. No candidtates for standard IV fibrinolytics. In centers with resources and expertise. within 6 hrs of sx onset. not yet approved by FDA. Mechanical clot disruption/Stent retrievers correct answer: tx for acute ischemic stroke. prestroke mRA score 0-1. rtPA within 4.5 hrs of sx onset. Occlusion of the internal carotid artery or proximal MCA. 18+ years old. NIHSS > 6. ASPECTS > 6. Groin puncture within 6 hrs of sx onset. General stroke care correct answer: support ABC. monitor glucose (hyperglycemia worsens, < 185). monitor BP. monitor temp. perform dysphagia screening. monitor for complications and fibrinolytic therapy. transfer to ICU if indicated. Ischemic Stroke tx when BP > 185/110. correct answer: Labetalol 10-20 mg IV 1-2 min may repeat x1. or Nicardipine IV 5mg/h. (can titrate up to 2.5mg/h every 5-15 min - max 15 mg/h). Hydralazine or enalaprilat may be considered. Ischemic Stroke tx when BP > 180-230/105-120 correct answer: Labetalol 10 mg IV followed by continuous IV 2-8 mg/min or Nicardipine IV 5mg/h. (can titrate up to 2.5mg/h every 5-15 min - max 15 mg/h). If BP is not controlled or diastolic BP >140 consider correct answer: Sodium Nitroprusside. BP monitoring for Ischemic Stroke when high correct answer: q15 min for 2 hrs after rtPA starts. then q30 min for 6 hrs. Then every hour for 16 hrs. During Cardiac Arrest the team leader will do the correct answer: Primary Assm Rhythm recognition (shock or not shock) defibrillation using manual defibrillator resuscitation drugs a discussion of IV or IO access advanced airways Chest Compression Feaction (CCF) correct answer: the proportion of time during cardiac arrest resusciation when compressions are performed. Should be as high as possible, at least 60% but ideally > 80%. Lower decreases ROSC and survival. Many patients with sudden cardiac arrest demonstrate correct answer: VF at some point in their arrest. What 2 rhythms require CPR until a defibrillator is available correct answer: VF and pulseless VT. Tx for VF and pulseless VT correct answer: high energy unsynchronized shocks. Epinephrine. Amiodarone. Lidocaine. Magnesium. Epinephrine correct answer: 1mg IV/IO q3-5 mins. (vasoconstriction increases cerebral and coronary blood flow). Amiodarone correct answer: First-line agent for cardiac arrest (improves ROSC). 300 mg IV/IO bolus. Then 1 additional 150 mg IV/IO. Blocks Na channels. Lengthens cardiac action potential. Lidocaine correct answer: Given if Amiodarone is unavailable. First dose 1-1.5mg/kg IV/IO. Then 0.5-0.75mg/kg IV/IO at 5-10 min intervals. Max dose 3 mg/kg. ET administration 2-4 mg/kg. Suppresses automaticity of heart conduction, increasing electrical stimulation of the ventricle/His-Purkinje system. Spontaneous depolarization of the ventricles during diastole. Blocks permeability of the neuronal membrane to Na ions (inhibits depolarization). Epinephrine, vasopressin, lidocaine. Dilute dose in 5-10 ml of sterile water or NS. Inject directly into tube. Fluid administration correct answer: Titrate to optimize BP, CO and systemic perfusion. Mean arterial pressure of > 65 mm Hg is goal. Hypovolemia: NS or LS. NOT D5W (reduces serum Na rapidly). Monitor electrolytes. Vasopressor administration correct answer: Optimize CO and BP. Epinephrine 1 mg IV/IO q3-5 min. If IV/IO cannot be established, give 2-2.5mg diluted in 5-10 ml sterile water or NS directly into the ET tube. Cardiac Arrest assoc with opioid overdose correct answer: Leading cause of unintentional injurious death ages 25-60. Causes CNS and respiratory depression. Most involve co-ingestion of multiple drugs or comorbidities. Opioid causes of torsades de pointes correct answer: Methadone and propoxyphene. Naloxone correct answer: Tx for opioid OD. Opioid receptor agonist in brain, spinal cord and GI. Can rapidly reverse CNS and respiratory depression. Given IV, IM, intranasally, SubQ, nebulized or ET tube. Give as soon as available. 2mg IN. 0.4mg IM/IV repeated q4 mins. PEA correct answer: Any organized rhythm without a pulse (even sinus rhythm). ***VF, pVT, asystole excluded.*** The most common initial condition present after successful defibrillation. correct answer: PEA. 2 common causes of PEA correct answer: Hypovolmeia and hypoxia. ***Search for underlying cause*** IV/IO access is priority over correct answer: inserting an advanced airway in PEA. (Unless bag-mask ventilation is ineffective or arrest is caused by hypoxia). Flat line correct answer: No discernible electrical activity on the EKG. True Asystole correct answer: Validate that the flat line is: not another rhythm (VF) and not the result of operator error (loose leads, no power, signal too low). Reasons to stop/withhold resuscitative efforts correct answer: Rigor mortis. DNAR status. Threat to safety of providers. When to consider stopping CPR correct answer: if ETCO2 is < 10 for 20 min. Tx for asystole correct answer: Epinephrine 1 mg IV/IO q3-5 min as soon as line is available. Continue CPR. You will see asystole most frequently in 2 situations correct answer: As a terminal rhythm that started with another rhythm. The first rhythm identified in a pt with unwitnessed or prolonged arrest. Symptomatic Bradycarida correct answer: HR < 50 with sx due to the HR. 3rd degree AV block is likely to cause correct answer: Cardiovascular collapse that requires immediate pacing. Bradyarrhythmia correct answer: HR < 60. When is bradycardia normal? correct answer: In well trained athletes (40-50 BPM). Functional (Relative) Bradycardia correct answer: HR in the normal sinus range, but the rate is insufficient for the pt. Ex: 70 is too slow for a pt in cardiogenic or septic shock. Bradycardia Sx correct answer: Chest discomfort/pain. SOB. Decreased LOC. Weakness. Fatigue. Light-headedness. Dizziness. Presynchope/Syncope. Bradycardia Signs correct answer: HypoTN. Orthostatic hypoTN. Diaphoresis. Pulmonary congestion. Frank CHF. PE. VT. If a pt is bradycardic and atropine doesn't work, what should you do? correct answer: Prepare TCP or consider dopamine or epinephrine infusion. First line tx for Bradycardia correct answer: Atropine 0.5 mg IV. May repeat to a total of 3 mg. Secondary tx for Bradycardia correct answer: TCP. Dopamine 2-20 mcg/kg/min. Epinephrine 2-10 mcg/min. When to avoid Atropine correct answer: 2nd deg heart block type 2. Third deg heart block. (treat with TCP or dopamine/epinephrine). (Don't wait for max of 3mg, move on after 2-3 doses).1 Atropine doses < 0.5mg may correct answer: paradoxically result in further slowing the HR. When to use atropine cautiously correct answer: Acute coronary ischemia or MI. (may worsen ischemia or increase infarct size). Set the TCP rate to correct answer: the lowest effective HR based on clinical assessment and sx resolution. After initiating TCP, confirm correct answer: Electrical and mechanical capture. Why is TCP only an emergent tx? correct answer: It is painful and not as reliable as trasvenous pacing. Most conscious pts should be given what before pacing? correct answer: Sedation. parenteral benzodiazepine for anxiety and muscle contractions. parenteral narcotic for analgesia. chronotropic infusion. expert consultation for transvenous pacing. What does TCP do? correct answer: Delivers pacing impulses to the heart through the skin by use of cutaneous electrodes. Indications for TCP correct answer: Hemodynamically unstable bradycarida (hypoTN, altered mental status, shock, ischemic chest discomofrt, acute HF). Unstable condition due to bradycardia. Symptomatic sinus brady. 2nd deg heart block type 2. 3rd deg heart block. new BBB or bifascicular block. Brady with symptomatic ventricular escape rhythms. Regular. Irregular. What does "Unstable" mean regarding tachycardias? correct answer: If the pt demonstrates rate- related cardiovasular compromise with sx (hypoTN, altered mental status, signs of shock, ischmeic chest discomfort, AHF). Proceed to cardioversion. (serious sx unlikely if HR <150). What does "stable" mean regarding tachycardias? correct answer: Does not have rate-related cardiovascular compromise. Time to get a 12 lead EKG. Time to determine rhythm. Seek expert consultation. If a tachycardic pt is pulseless treat as correct answer: VF. If a tachycardic pt has a wide-complex assume it is correct answer: VT until proven otherwise. If the pt is unstable, has a pulse with regular uniform wide-complex VT (monomorphic VT) tx with correct answer: Synchronized cardioversion at 100 J (monophasic). ***if no response from first shock, increase dose and continue. Polymorphic QRS (poly VT or torsades de pointes) tx with correct answer: Unsynchronized high-energy shocks (defibrillation doses). If there is any doubt about whether an unstable pt has monomorphic or polymorphic VT provide correct answer: high-energy unsynchronized shocks. What is a wide QRS? correct answer: > 0.12 sec. Unsynchronized Shock correct answer: An electrical shock that will be delivered as soon as the operator pushes the SHOCK button to discharge the defibrillator. Thus the shock can fall anywhere within the cardiac cycle. High energy levels. Synchronized shock correct answer: use sensor to deliver shock that is synchronzied with the R wave. avoid delivery shock during cardiac repolarization (T wave), as a shock on T wave can precipitate VF (***if it does, defibrillate!). Lower energy levels. When to use synchronized shocks correct answer: Unstable SVT. Unstable Afib. Unstable A flutter. Unstable monomorphic tachy with pulses. When to use unsynchronized shocks correct answer: Pulseless. Pt with clinical deterioration (pre-arrest) when you think a delay in converting the rhythm will cause cardiac arrest. Unsure if VT is monomorphic or polymorphic. Unstable A fib tx correct answer: Monophasic cardioversion: initial 200 J synchronized shock. Biphasic cardioversion: 120-200 J synchronized shock. Escalate as needed. Atrial flutter and SVT tx correct answer: 50-100 J. Monomorphic VT with a pulse tx correct answer: 100 J. Increase dose as needed. Steps to Synchronized Cardioversion correct answer: Sedate conscious pts unless deteriorating rapidly. Turn on defibrillator (monophasic or biphasic). Attach leads (white to right, red to ribs, what's left over L shoulder). Put adhesive electrode pads on pt. Press "sync." Look for markers on the R wave indicating sync mode. Select appropriate energy level. Announce "stand clear!" Press "charge." Clear the patient. Press "shock." Check monitor, increase energy if tachycardia persists. Re-activate synch mode after each shock. Narrow QRS complex (SVT) tachycardias (< 0.12 sec) correct answer: Sinus Tachy (most frequent) A FIB. A flutter. AV nodal reentry (least frequent) Wide QRS complex tachycardias (>0.12 sec) correct answer: Monomorphic VT Polymorphic VT SVT with aberrancy Regular or irregular tachycardias correct answer: Irregular narrow-complex tachycardias are probably atrial fibrillation Sinus Tachy correct answer: >100 BPM. generated by sinus node discharge. HR does not exceed 220. (usually not over 120-130). Age related. Gradual onset and termination. Caused by external influences (fever, anemia, hypoTN, blood loss, exercise). Rate slowed by vagal maneuvers. Cardioversion contraindicated. B-Blockers may cause clinical deterioration. Cardiac Output correct answer: stroke volume x heart rate What happens if you decrease HR in compensatory tachycardia? correct answer: CO will fall and condition will likely deteriorated. When to cardiovert for sinus tachy correct answer: If significant sx are due to rhythm and pt is unstable. When to deliver unsynchronized high-energy shocks (defib) for sinus tachy correct answer: If the pt develops pulseless VT. If the pt has polymorphic VT treat ass correct answer: VF: deliver high-energy unsynchronized shocks. If HR > 150 correct answer: It is typically not sinus tachy, it is a tachyarrhthymia. The most common life-threatening wide-complex tachys correct answer: are likely to deteriorate to VF. Monomorphic VT. Polymorphic VT. IV adenosine for both tx and dx of tachys correct answer: If the rhythm etiology cannot be determined and regular rate is monomorphic. IV antiarrhythmic drugs correct answer: Procainamine. Amiodareone. Sotalol. Meds to avoid in Irregular Wide-Complex Tachy correct answer: Adenosine. Ca Channel Blockers. Digoxin. Possibly B-Blockers if pt has pre-excitation Afib.