ACLS 2024 Questions with complete solution, Exams of Nursing

Download ACLS 2024 Questions with complete solution and more Exams Nursing in PDF only on Docsity! ACLS 2024 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. 2 most common causes of PEA - correct answer Hypoxia and hypovolemia. PEA hypovolemia - correct answer rapid, narrow-complex tachycardia (sinus tachy). Increased diastolic, decreased systolic pressure. BP drops. Narrow QRS. Common causes: occult internal hemorrhage, severe dehydration. Consider volume infusion. acute coronary syndrome - correct answer sudden symptoms of insufficient blood supply to the heart indicating unstable angina or acute myocardial infarction Tx for PE - correct answer Fibrinolytics. Tx for cardiac tamponade - correct answer pericardiocentesis. tx for Tension pneumo - correct answer needle aspiration and chest tube placement. Drug overdose/toxic exposure - correct answer may lead to peripheral vascular dilation and/or myocardial dysfunction with hypotension. Tx: prolonged basic CPR, etracorporeal CPR, intra-aortic balloon pumping, renal dialysis, IV lipid emulsion, digoxin, glucagon, bicarbonate, transcutaneous pacing, correction of electrolyte imbalances. Normal respiratory rate. Normal tidal volume. - correct answer 12-16/min. 8-10 ml/kg. ***<6 = assisted ventilation with BVM or advanced airway with 100% O2. Respiratory Distress - correct answer abnormal respiratory rate or effort. Sx: nasal flaring, retractions, use of accessory muscles, hypoventilation, bradypnea, stridor, wheezing, grunting, tachycardia, cyanosis, changes in LOC, agitation, use of abdominal muscles. Mild respiratory distress sx - correct answer mild tachypnea and mild increase in respiratory effort with changes in airway sounds. Severe respiratory distress sx - correct answer tachypnea, increased respiratory effort, deterioration in skin color, changes in mental status. Can be indicitive of respiratory failure. Respiratory Failure - correct answer inadequate oxygenation, ventilation or both. Often the end stage of respiratory distress. Confirm dx with objective measures (pulseOx, ABGs). Sx of respiratory failure - correct answer marked tachypnea, bradypnea, apnea (late), increased/decreased/no effort, poor/absent distal air movement, tachycardia (early), bradycardia (late), cyanosis, stupor, coma (late). Causes of respiratory failure - correct answer upper or lower airway obstruction. Lung tissue disease. Disordered control of breathing. Rise in arterial CO2 (hypercapnia). Drop in blood O2. Respiratory arrest - correct answer the cessation of breathing. Caused by drowning or head injury. Tx: tidal volume 500-600ml (visable chest rise). ***Pts with airway obstruction or poor lung compliance may require higher pressures. Complications of excessive ventilation - correct answer gastric inflation. regurgitation. aspiration. Intrathoracic pressure increase --> decreased venous return to heart --> low cardiac output. cerebral vasoconstriction --> decreased blood to brain. The most common cause of upper airway obstruction in an unconscious pt - correct answer loss of tone in the throat muscles --> tongue occluding airway. 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. ***Inappropriate dosing and monitoring can lead to excess intracerebral bleeding and major hemorrhage with STEMI! When to administer IV Nitroglycerin - correct answer Routine use not indicated. Used in ischemic syndromes. Recurrent or continuing chest discomfort unresponsive to spray or tablet. Pulmonary edema complicating STEMI. HTN complicating STEMI. Is preferred over topical or long acting forms because it can be titrated. IV Nitro treatment goals - correct answer SBP > 90 mmHg. Limit drop in SPB to 30 mmHg below baseline in HTN pts. In an acute stroke which takes priority? EKG or CT scan - correct answer CT scan. No arrhythmias are specific to stroke, but look for causes of embolisms (Afib). Stroke - correct answer Acute neurologic impairment that follows interruption in blood supply to a specific area of the brain. Ischemic stroke - correct answer 87% caused by an occlusion of an artery. Hemorrhagic stroke - correct answer 13% Occurs when a blood vessel suddenly ruptures into the surrounding tissue. FIBRINOLYTICS & ANTICOAGs CONTRAINDICATED! Leading cause of death in the U.S. - correct answer Stroke. (Most occur at home). Start IV Fibrinolytics for stroke - correct answer within 3 hrs of symptom onset. (4.5 in some patients. 6 hrs Endovascular tx). 8 D's of stroke care - correct answer Detection Dispatch (EMT) Delivery (transport) Door (triage) Data (eval) Decision (therapy selection) Drug/Device (Fibronolytics or endovascular) Disposition (rapid admission to stroke unit) NINDA critical in-hospital stroke time goals - correct answer 1. Immediate general assm by stroke team or ER doc within 10 min of arrival. Order non- contrast CT. 2. Neuro assm by stroke team within 25 min of arrival. 3. Interpret CT scan within 45 min. 4. Fibrinolytics within 1 hr of arrival + 3 hrs sx onset. 5. Dor-to-admission time 3 hrs. Sx of stroke - correct answer Sudden weakness/numbness in face, arm, leg (especially one sided). Sudden confusion. Trouble speaking/understanding. 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. 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). Magnesium - correct answer For torsades de pointes (Polymorphic VT - long QT interval). PREVENTING recurrent VT. Also for low levels, alcoholism or malnutrition. Loading dose 1-2g IV/IO diluted in 10 ml (D5W or NS). Normal 35-40. Central Venous O2 Saturation - correct answer Changes reflect alterations in O2 delivery from changes in CO. Measured continuously by an oximetric tipped CV catheter in the SVC or pulmonary artery. Normal 60-80%. If < 30% improve compressions and vasopressor therapy. Tx of VF/pVT in hypothermia - correct answer Severe <30C (86F). Moderate 30-34C (86-93.2F). Perform BLS with active rewarming. Pt may have reduced rate of drug metabolism (drugs can accumulate to toxic levels). No antiarrthymic meds. Consider administering a vasopressor. For moderate: give drugs spaced at longer intervals. IV administration - correct answer For drug and fluids unless a central line is already available. (Central line access may cause interruptions in CPR and cause lacerations, hematomas and bleeding). Does not require interruption in CPR. Drugs take 1-2 min to reach central circulation. Give drug by bolus injection. Follow with 20 ml fluid. Elevate extremity for 10-20 sec. IO administration - correct answer Access can be established in all age groups. Access takes 30-60 secs. Preferred over ET administration. Any ACLS drug or fluid administered IV can be given this way. Provides access to a noncollapsible marrow venous plexus. Rapid, sage and reliable rout for giving drugs, crystalloids, colloids, blood. Uses a rigid needle specifically from a kit. ET administration - correct answer Other routes are preferred. Optimal drug dose is unknown. Typical dose of drugs is 2-2.5X IV route. CPR will need to be stopped to prevent regurgitation of mediation. 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. 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. Precautions for TCP - correct answer Hypothermia. Asystole. Conscious pts require analgesia. Do not assess carotid pulse to confirm mechanical capture (electrical stimulation causes muscular jerking that may mimic it). Performing TCP - correct answer Place electrodes on chest according to package instructions. Turn pacer on. Set 60 BPM (adjust rate based on clinical response). Set current milliamperes output 2 mA above the dose at which consistent capture is observed (safety margin). Higher heart rates - correct answer can worsen ischemia, HR is a major determinate of myocardial O2 demand. Ischemia leads to arrythmias. Brady with escape rhythms - correct answer When HR falls, the electrically unstable ventricle may "escape" suppression by higher and faster pacemakers (Sinus node), especially during acute ischemia. This often fails to respond to drugs. Ventricular Fibrillation - correct answer Asystole - correct answer First degree AV block - correct answer prolonged PR interval Atrial flutter > 150 BPM - correct answer Cardioversion is often required. Key to management of a tachycardia - correct answer determine if the patient has a pulse or not!!! determine if the patient is stable or unstable!!! What do you do next if the patient is in stable tachycardia? - correct answer Eval EKG and determine if the QRS is: Wide. Narrow. 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). 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. May cause a paradoxical increase in ventricular response. Therapy for narrow QRS with regular rhythm - correct answer Vagal maneuvers/carotid massage. Adenosine. If SVT does not respond to vagal maneuvers give - correct answer 6mg rapid IVP in antecubital vein over 1 sec. Flush with 20 ml NS. Elevate arm immediately. If it doesn't convert in 1-2 min, give second dose of 12 mg. Repeat flush and elevation. What does Adenosine do to Afib or flutter? - correct answer Won't terminate, but will slow conduction. This allows identification of rhythm. Reduce Adenosine to 3mg if - correct answer Pt is taking Dipyridamole or Carbamazepine. When to avoid giving Adenosine - correct answer Asthma or COPD. Causes Bronchospasm. If rhythm converts with Adenosine - correct answer if is probably reentry SVT. Tx with more medication or AV nodal blockers (Verapamil, diltiazem, B- blockers). If rhythm doesn't covert with Adenosine it is likely - correct answer A-flutter. Ectopic atrial tachycardia. Junctional tachycardia. Caution is advised when combining AV nodal blocking agents such as - correct answer Ca Channel Blockers or B-blockers. When do most deaths occur following cardiac arrest - correct answer In the first 24 hrs. TTM impacts - correct answer survival and neurologic function after cardiac arrest. Interventions for unconscious pts after cardiac arrest - correct answer Advanced airway for mechanical support. Elevate HOB 30 deg to reduce cerebral edema, aspiration and VAP. Monitor waveform capnography. Continuous pulse ox. What does hyperventilation do? - correct answer Increases Intrathoracic pressure, which decreases preload and lowers CO. This also decreases cerebral blood flow. Start ventilations at 10. When to use TTM - correct answer Should be considered for any pt who is comatose and unresponsive to verbal commands after ROSC. The most common cause of cardiac arrest - correct answer Cardiovascular disease and associated coronary ischemia. ***Get EKG to detect ST and LBBB. When to determine prognosis after cardiac arrest - correct answer After 72 hrs of resuscitation and wait until pt returns to normothermia if treated with TTM. What to avoid during ventilation - correct answer Ties that pass circumferentially around pt's neck. Excessive ventilation that can lead to decrease in cerebral blood flow.