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.
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
✓
B.
Coagulopathy (impaired clotting factor synthesis)
✓
A.
Vasopressin is not working
✓
B.
Vasopressin-induced myocardial ischemia, requiring immediate physician notification and possible discontinuation
✓
B.
Ventricular fibrillation
✓
D.
Supraventricular tachycardia
✓
A.
Administer oral glucose
✓
B.
Administer IV dextrose (e.g., D50W) stat
✓
D.
Administer a diuretic
✓
B.
Assess for causes (e.g., agitation, coughing, EVD obstruction), ensure proper EVD drainage, and notify physician
✓
C.
Lower the head of the bed
✓
D.
Administer more fluid
✓
B.
Elevate head of bed 30-45 degrees, daily sedation holidays, oral care with chlorhexidine, and DVT/stress ulcer prophylaxis
✓
C.
Frequent suctioning only
✓
D.
Allowing patient to self-extubate
✓
B.
Intracranial hemorrhage, requiring immediate discontinuation of fibrinolytic and urgent CT scan
✓
C.
Reperfusion arrhythmia
✓
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
✓
