B.
Ventricular fibrillation
✓
D.
Supraventricular tachycardia
✓
A.
Vasopressin is not working
✓
B.
Vasopressin-induced myocardial ischemia, requiring immediate physician notification and possible discontinuation
✓
B.
Coagulopathy (impaired clotting factor synthesis)
✓
A.
Inflate the balloon further
✓
B.
Immediately deflate the balloon and pull back slightly to prevent pulmonary artery rupture
✓
C.
Inject air into the balloon
✓
D.
Administer a diuretic
✓
A.
Administer oral pain medication
✓
B.
Administer oxygen, nitroglycerin, aspirin, and morphine (MONA) as ordered, and obtain 12-lead ECG
✓
C.
Administer a diuretic
✓
A.
Insufficient pain control
✓
B.
Opioid-induced respiratory depression, requiring physician notification and possible dose reduction or naloxone administration
✓
C.
Pain is well controlled
✓
A.
Increase respiratory rate
✓
B.
Increase tidal volume or decrease respiratory rate to blow off more CO2
✓
C.
Decrease tidal volume
✓
A.
Patient is over-hydrated
✓
B.
Furosemide resistance or worsening kidney injury, requiring physician notification and alternative strategies
✓
C.
Patient is dehydrated
✓
D.
Patient needs more sodium
✓
A.
Guess the infusion rate
✓
B.
Program the correct drug, concentration, and dose, and verify against order and second nurse
✓
C.
Override all safety alarms
✓
D.
Use a pump that is not calibrated
✓
A.
Increase environmental stimulation
✓
B.
Assess for pain, discomfort, or other causes of agitation, and administer analgesia/sedation as ordered to prevent further ICP elevation
✓
C.
Apply physical restraints immediately
✓
D.
Administer a diuretic
✓
A.
Administer oral antacids
✓
B.
Establish large-bore IV access, administer IV fluids/blood products, and prepare for endoscopic intervention
✓
C.
Administer a diuretic
✓
A.
Patient is absorbing nutrients well
✓
B.
Delayed gastric emptying and high risk of aspiration
✓
C.
Patient is dehydrated
✓
A.
Administer more fluids
✓
B.
Slow down or stop fluid administration, elevate head of bed, and notify physician
✓
C.
Administer a vasopressor
✓
D.
Administer an antibiotic
✓
B.
Intracranial hemorrhage, requiring immediate discontinuation of fibrinolytic and urgent CT scan
✓
C.
Reperfusion arrhythmia
✓
A.
Warm the blood in a microwave
✓
B.
Verify patient identity and blood product according to hospital policy with a second licensed professional
✓
C.
Administer without consent
✓
D.
Infuse rapidly without monitoring
✓
B.
Increased intracranial pressure (ICP) with brainstem compression
✓
B.
Initiate CPR immediately and administer epinephrine as ordered
✓
C.
Synchronized cardioversion
✓
A.
Increase the blood flow rate
✓
B.
Apply direct pressure to the site, notify physician, and assess coagulation status
✓
C.
Administer more fluid
✓
D.
Stop CRRT without orders
✓
A.
Insufficient dobutamine dose
✓
B.
Dobutamine-induced tachycardia and myocardial ischemia, requiring physician notification and possible dose adjustment
✓
