A.
Patient is recovering
✓
B.
Brain herniation, requiring immediate neurosurgical intervention
✓
A.
Prepare without double-check
✓
B.
Use an infusion pump with dose error reduction system (DERS) and perform independent double-check with another nurse
✓
C.
Administer as a bolus
✓
D.
Use a gravity infusion
✓
A.
Patient is well hydrated
✓
B.
Worsening acute kidney injury or inadequate renal perfusion
✓
C.
Patient is over-hydrated
✓
D.
Patient needs more fluids
✓
A.
Nitroglycerin is not working
✓
B.
Nitroglycerin-induced hypotension, requiring patient to lie down, fluid bolus if ordered, and physician notification
✓
A.
Immediately apply restraints
✓
B.
Assess for underlying causes (e.g., pain, hypoxemia, delirium), and administer appropriate sedation/analgesia as ordered
✓
C.
Leave patient unattended
✓
D.
Increase the ventilator settings
✓
B.
Hepatic encephalopathy and coagulopathy
✓
A.
Apply a warm compress
✓
B.
Apply direct pressure to the site, notify physician, and assess for hematoma formation
✓
C.
Remove the arterial line without pressure
✓
D.
Administer a diuretic
✓
A.
Administer insulin only
✓
B.
Administer aggressive intravenous fluid resuscitation with normal saline
✓
C.
Administer oral glucose
✓
D.
Administer a diuretic
✓
A.
Insufficient dobutamine dose
✓
B.
Dobutamine-induced tachycardia and increased myocardial oxygen demand, requiring physician notification and possible dose reduction
✓
A.
To increase heart rate
✓
B.
To relieve pain and reduce myocardial oxygen demand
✓
D.
To increase blood pressure
✓
A.
Continue the infusion
✓
B.
Stop the infusion immediately, aspirate residual drug, and administer phentolamine or terbutaline (antidote) locally if ordered
✓
C.
Increase the infusion rate
✓
B.
Inadequate anticoagulation or filter malfunction
✓
B.
Assess patient's respiratory effort, check for disconnection, and ensure appropriate ventilator settings
✓
C.
Increase the tidal volume
✓
D.
Decrease the respiratory rate
✓
A.
Administer oral fluids
✓
B.
Secure the airway, support ventilation, and administer antidote if available (e.g., naloxone)
✓
C.
Administer a diuretic
✓
A.
Patient needs more vasopressin
✓
B.
Vasopressin-induced coronary vasoconstriction, requiring physician notification and potential discontinuation
✓
A.
Insufficient norepinephrine dose
✓
B.
Norepinephrine-induced tachycardia, requiring physician notification and possible dose reduction
✓
B.
Central fever (neurogenic fever) or infection
✓
B.
Prime the tubing to remove air bubbles, and ensure all connections are secure
✓
C.
Increase the infusion rate
✓
D.
Decrease the infusion rate
✓
