B.
Hypovolemic shock (due to fluid shifts and capillary leak)
✓
A.
Increase HFNC flow rate
✓
B.
Prepare for intubation and mechanical ventilation
✓
C.
Administer a sedative only
✓
D.
Administer more HFNC oxygen
✓
A.
Achieve MAP < 50 mmHg
✓
B.
Achieve a target MAP of 65 mmHg or higher
✓
C.
Achieve MAP > 100 mmHg
✓
D.
Achieve a heart rate of 150 bpm
✓
B.
Pancreatic necrosis with hemorrhage or peritonitis
✓
A.
Apply suction continuously during insertion
✓
B.
Pre-oxygenate the patient before suctioning, limit suctioning time to 10-15 seconds, and apply suction only on withdrawal
✓
C.
Suction for prolonged periods
✓
D.
Use a small catheter
✓
A.
Administer more fluids
✓
B.
Monitor serum osmolality and electrolytes, and assess for fluid balance and urine output
✓
D.
Administer a diuretic
✓
A.
Increase the flush bag pressure
✓
B.
Check for air bubbles, kinks, or clot in the line, and flush the system
✓
C.
Decrease the flush bag pressure
✓
D.
Re-zero the transducer
✓
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
✓
