Code management
A patient becomes unresponsive. No pulse is palpated within 10 seconds. What is the nurse’s FIRST action?
A. Apply defibrillator pads
B. Begin chest compressions
C. Call the provider
D. Administer epinephrine
B. Begin chest compressions
A patient on assist-control ventilation has the following ABG:
pH 7.48, PaCO₂ 30, HCO₃ 24, PaO₂ 92.
Which ventilator adjustment does the nurse anticipate?**
A. Increase tidal volume
B. Increase respiratory rate
C. Decrease respiratory rate
D. Increase FiO₂
C. Decrease respiratory rate
Rationale:
The pH is alkalotic and the PaCO₂ is low → respiratory alkalosis. The patient is blowing off too much CO₂. On assist-control, either the set rate is too high or the patient is overbreathing. Decreasing the respiratory rate reduces minute ventilation and allows CO₂ to rise back toward normal. Oxygenation (PaO₂ 92) is fine, so FiO₂ does not need adjustment.
A patient with severe pancreatitis becomes tachycardic (HR 122), restless, and has a BP of 118/74. Urine output has dropped to 25 mL/hr. Lactate is 3.8 mmol/L. What is the best interpretation?
A. The patient is stable because BP is normal
B. The patient is in compensatory shock
C. The patient is in refractory shock
D. The patient has cardiogenic shock
Answer: B
Rationale:
BP is still maintained, meaning compensatory mechanisms (SNS + RAAS) are working. However:
Tachycardia ✔
Oliguria ✔
Elevated lactate ✔
Restlessness ✔
These are early signs of inadequate perfusion. Hypotension is a late sign. The elevated lactate confirms tissue hypoxia. This is compensatory shock — still potentially reversible.
A patient with septic shock begins oozing from IV sites. Platelets are 42,000, PT and aPTT are prolonged, fibrinogen is low, and D-dimer is elevated. What condition is most likely?
A. HIT
B. ITP
C. DIC
D. TTP
Answer: C
Rationale:
This is Disseminated Intravascular Coagulation (DIC).
Lab pattern for DIC:
↓ Platelets
↑ PT
↑ aPTT
↓ Fibrinogen
↑ D-dimer
Bleeding + microclots
DIC = widespread clotting → consumption of clotting factors → bleeding.
Sepsis is a common trigger.
The monitor shows ventricular fibrillation. The patient has no pulse. What is the priority intervention?
A. Administer epinephrine
B. Begin synchronized cardioversion
C. Deliver unsynchronized defibrillation
D. Administer amiodarone
C. Deliver unsynchronized defibrillation
A ventilated patient suddenly develops high peak inspiratory pressures (PIP), decreased tidal volume delivery, and absent breath sounds on the right side. What is the priority concern?
A. Pulmonary edema
B. Tension pneumothorax
C. Secretions
D. Oxygen toxicity
Answer: B
Rationale:
High PIP + unilateral absent breath sounds = likely tension pneumothorax. This is an emergency. Air is trapped in the pleural space, increasing intrathoracic pressure and reducing lung expansion. This is not a secretion issue because breath sounds are absent on one side, not coarse bilaterally. Immediate provider notification and decompression are needed.
A patient in septic shock receives aggressive fluid resuscitation. BP improves temporarily but becomes hypotensive again within 30 minutes. CVP is elevated. What is the most likely explanation?
A. Hypovolemia
B. Ongoing vasodilation and capillary leak
C. Decreased preload
D. Neurogenic shock
Answer: B
Rationale:
In septic shock:
Massive vasodilation
Capillary permeability increases
Fluid shifts into interstitial space
Even if CVP is elevated (fluids given), the vasculature remains dilated and “leaky,” so BP drops again. This patient likely now needs vasopressors. This is distributive physiology, not volume loss.
A patient diagnosed with HIT requires anticoagulation. Which medication should the nurse anticipate?
A. Warfarin
B. Aspirin
C. Argatroban
D. Enoxaparin
Answer: C
Rationale:
In HIT:
Heparin is stopped.
You must start a non-heparin anticoagulant.
Argatroban is a direct thrombin inhibitor used in HIT.
⚠️ Warfarin is NOT started immediately because it can cause skin necrosis in HIT.
Enoxaparin (LMWH) is still heparin-based — contraindicated.
A patient is in pulseless electrical activity (PEA). What is the priority action?
A. Defibrillate
B. Synchronized cardioversion
C. CPR and epinephrine
D. Amiodarone
C. CPR and epinephrine
A patient’s FiO₂ has been 85% for 72 hours. What complication is the nurse most concerned about?
A. Respiratory acidosis
B. Oxygen toxicity
C. Atelectasis
D. Hypercapnia
Answer: B
Rationale:
Prolonged high FiO₂ (>60%) increases risk for oxygen toxicity due to free radical damage and alveolar injury. The goal is always to titrate FiO₂ down as quickly as possible while maintaining adequate oxygenation. Hypercapnia is related to ventilation, not oxygen concentration.
A patient with acute MI develops hypotension, crackles, cool clammy skin, and altered mental status. Which intervention would be MOST harmful?
A. Initiating inotropic therapy
B. Administering large fluid boluses rapidly
C. Preparing for possible mechanical support
D. Monitoring urine output hourly
Answer: B
Rationale:
This is cardiogenic shock. The problem is pump failure, not volume deficit.
Giving large fluid boluses:
Increases preload
Worsens pulmonary edema
Further decreases oxygenation
Inotropes help contractility. Mechanical support (IABP/VAD) may be needed. Fluids would worsen the condition.
A patient with DIC is bleeding from gums and IV sites but also has signs of organ ischemia. Why does this occur?
A. Excessive platelet production
B. Simultaneous clotting and bleeding
C. Inadequate fibrinolysis only
D. Decreased immune response
Answer: B
Rationale:
DIC is a paradox:
Widespread microclots form in circulation.
Clotting factors and platelets get used up.
Then the patient bleeds.
So you see:
Oozing
Organ failure
Skin necrosis
Elevated D-dimer
It’s both clotting and bleeding at the same time.
During a code, epinephrine was just administered. What is the next priority?
A. Check pulse
B. Resume CPR immediately
C. Check rhythm
D. Administer amiodarone
B. Resume CPR immediately
A patient on mechanical ventilation becomes hypotensive after sedation is increased and PEEP is raised. Urine output drops. What is the most likely cause?
A. Improved oxygenation
B. Increased venous return
C. Decreased preload from increased intrathoracic pressure
D. Fluid overload
Answer: C
Rationale:
Both sedation (vasodilation) and increased PEEP raise intrathoracic pressure, which decreases venous return to the heart. Decreased preload → decreased cardiac output → hypotension and oliguria. This is a hemodynamic complication of positive pressure ventilation
A patient with spinal cord injury at T4 presents with hypotension, bradycardia, and warm dry skin. Which physiologic mechanism explains these findings?
A. Excessive parasympathetic stimulation
B. Decreased preload
C. Increased systemic vascular resistance
D. Decreased myocardial contractility
Answer: A
Rationale:
Neurogenic shock = loss of sympathetic tone. Without SNS:
No vasoconstriction → hypotension
Unopposed parasympathetic tone → bradycardia
Warm, dry skin (no vasoconstriction)
It is not primarily a preload or contractility issue — it’s loss of vascular tone and autonomic imbalance.
Which assessment finding would be more consistent with HIT than DIC?
A. Oozing from venipuncture sites
B. Petechiae and ecchymosis
C. New pulmonary embolism
D. Prolonged PT and aPTT
Answer: C
Rationale:
HIT is primarily a thrombotic disorder.
You’re looking for:
New DVT
PE
Stroke
Limb ischemia
DIC presents more with bleeding and abnormal coag labs. HIT usually does NOT cause prolonged PT/aPTT unless something else is occurring.
A patient with symptomatic bradycardia (HR 32, hypotension, altered LOC) is unresponsive to atropine. What is the next priority?
A. Defibrillation
B. Transcutaneous pacing
C. Adenosine
D. Amiodarone
B. Transcutaneous pacing
A ventilator alarm indicates “low exhaled tidal volume.” The nurse notes the patient is awake and anxious but oxygen saturation is stable. What is the priority action?
A. Increase tidal volume setting
B. Check for circuit disconnection or leak
C. Suction the patient
D. Increase FiO₂
Answer: B
Rationale:
Low exhaled tidal volume alarms usually indicate a leak or disconnection in the ventilator circuit. The priority is to assess the system first (airway, tubing, connections). You never adjust settings before assessing equipment integrity. Suctioning is indicated for high pressure alarms, not low volume alarms.
A patient with sepsis initially has warm flushed skin and bounding pulses. Six hours later, skin becomes cool, BP drops to 82/40, and lactate increases to 7 mmol/L. What does this progression indicate?
A. Resolution of septic shock
B. Transition from compensatory to progressive shock
C. Development of neurogenic shock
D. Hypovolemic shock from bleeding
Answer: B
Rationale:
Early septic shock:
Vasodilation
Warm skin
Bounding pulses
Later:
Myocardial depression
Persistent hypoperfusion
Rising lactate
Hypotension
Cool skin
This is progression into the decompensated/progressive stage. The body can no longer compensate, and organ dysfunction is worsening.
A patient with sepsis develops DIC. Which intervention is priority?
A. Administer heparin immediately
B. Treat the underlying infection
C. Transfuse platelets regardless of bleeding
D. Restrict fluids
Answer: B
Rationale:
DIC is secondary to another condition.
You must treat the underlying cause (in this case, sepsis).
Supportive therapy may include:
Platelets
FFP
Cryoprecipitate
But fixing the trigger is the priority.