NRNP6566 2021 June Week 11 Knowledge Check Latest

NRNP6566 Advanced Care of Adults in Acute Settings I

Week 11 Knowledge Check  

Question 1          Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:

Significant History

Type 2 DM x 4 years, HTN

Medications

Lisinopril 10 mg daily

Metformin 1000 mg po daily

Glipizide 5 mg po daily

Physical Exam

Pale, lethargic gentleman

Skin is very dry

VS  94/64   P 112  RR 30  T  99.4   wt 195 pounds  ht 5’11 »

Lungs clear bilaterally, rapid respiration

CV :   RRR, no murmurs or gallops

Abd:  soft, non-tender, positive bowel sounds

Labs:

Hb  146    Hct  58%   Cr  4.9   Bun  53    Cholesterol  238

Na  126  K  5.6  CL 95    Ca  8.8   Gluc 722  Phosphorus 5.8

Ketone  Moderate  AST  248  Alk Phos  132

ABG’s

             ph  7.01

             Pco2  20

             Po2  100

             Sat    98% (on room air)

             HCO3   7.5

 What is the “ corrected” sodium level for the hyperglycemia? What does this mean and how would it impact your treatment plan for this patient?                                               

Question 2          Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:

Significant History

Type 2 DM x 4 years, HTN

Medications

Lisinopril 10 mg daily

Metformin 1000 mg po daily

Glipizide 5 mg po daily

Physical Exam

Pale, lethargic gentleman

Skin is very dry

VS  94/64   P 112  RR 30  T  99.4   wt 195 pounds  ht 5’11 »

Lungs clear bilaterally, rapid respiration

CV :   RRR, no murmurs or gallops

Abd:  soft, non-tender, positive bowel sounds

Labs:

Hb  146    Hct  58%   Cr  4.9   Bun  53    Cholesterol  238

Na  126  K  5.6  CL 95    Ca  8.8   Gluc 722  Phosphorus 5.8

Ketone  Moderate  AST  248  Alk Phos  132

ABG’s

             ph  7.01

             Pco2  20

             Po2  100

             Sat    98% (on room air)

             HCO3   7.5

 What patient education would be important to provided related to sick day management of his diabetes (include management of insulin) ?                                           

Question 3          A 44 year old female with history of type 2 diabetes taking metformin is admitted to the ICU following percutaneous placement of two coronary stents. Her chest pain is completely resolved. Twelve hours after the procedure the NP is contacted by the ICU nurse. The patient is experiencing shortness of breath, severe muscles pain, chilled, and a slow irregular heart beat. The patients ankles are swollen. The most recent labs show a Bun of 44 and Cr of 3.1. What do you suspect is happening with this patient?                                        

Question 4          A 37 year old female with a 20 year history of DM is post cholecystectomy with complications. She has been on four time daily blood sugar testing with sliding scale insulin coverage. She is preparing for discharge and wanted to return to her previous blood sugar management. Her pre-hospitalization insulin regime included:

                NPH insulin 16 units in AM and 8 units in PM

                Regular insulin 8 units in am and 3 units in PM

She resumed this regime 2 days ago. Upon rounding this am, the patient tells the NP that she has woken up feeling awful. She is sweaty and shaky during the night and lethargic in the morning. The NP reviews her blood sugar readings and discovers this:

0300       0700       1200       1700       2100

62           196         109         90           146

64           203         82           100         150

What is your working diagnosis for this patient?                                               

Question 5          How would you differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)?                                           

Question 6          Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:

Significant History

Type 2 DM x 4 years, HTN

Medications

Lisinopril 10 mg daily

Metformin 1000 mg po daily

Glipizide 5 mg po daily

Physical Exam

Pale, lethargic gentleman

Skin is very dry

VS  94/64   P 112  RR 30  T  99.4   wt 195 pounds  ht 5’11 »

Lungs clear bilaterally, rapid respiration

CV :   RRR, no murmurs or gallops

Abd:  soft, non-tender, positive bowel sounds

Labs:

Hb  146    Hct  58%   Cr  4.9   Bun  53    Cholesterol  238

Na  126  K  5.6  CL 95    Ca  8.8   Gluc 722  Phosphorus 5.8

Ketone  Moderate  AST  248  Alk Phos  132

ABG’s

             ph  7.01

             Pco2  20

             Po2  100

             Sat    98% (on room air)

             HCO3   7.5

What are the appropriate initial orders to treat this patient?                                       

Question 7          A 56 year old male with an acute COPD exacerbation is admitted to the ICU. He has type I diabetes and utilizes NPR and regular insulin twice a day to manage his diabetes. He is currently taking very little orally due to his shortness of breath. What would the best way to manage his diabetes and insulin needs in the ICU?                     

Question 8          Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:

Significant History

Type 2 DM x 4 years, HTN

Medications

Lisinopril 10 mg daily

Metformin 1000 mg po daily

Glipizide 5 mg po daily

Physical Exam

Pale, lethargic gentleman

Skin is very dry

VS  94/64   P 112  RR 30  T  99.4   wt 195 pounds  ht 5’11 »

Lungs clear bilaterally, rapid respiration

CV :   RRR, no murmurs or gallops

Abd:  soft, non-tender, positive bowel sounds

Labs:

Hb  146    Hct  58%   Cr  4.9   Bun  53    Cholesterol  238

Na  126  K  5.6  CL 95    Ca  8.8   Gluc 722  Phosphorus 5.8

Ketone  Moderate  AST  248  Alk Phos  132

ABG’s

             ph  7.01

             Pco2  20

             Po2  100

             Sat    98% (on room air)

             HCO3   7.5

How and when would you switch the patient from IV insulin to SQ insulin?                                          

Question 9          A 37 year old female with a 20 year history of DM is post cholecystectomy with complications. She has been on four time daily blood sugar testing with sliding scale insulin coverage. She is preparing for discharge and wanted to return to her previous blood sugar management. Her pre-hositalization insulin regime included:

                NPH insulin 16 units in AM and 8 units in PM

                Regular insulin 8 units in am and 3 units in PM

She resumed this regime 2 days ago. Upon rounding this am, the patient tells the NP that she has woken up feeling awful. She is sweaty and shaky during the night and lethargic in the morning. The NP reviews her blood sugar readings and discovers this:

0300       0700       1200       1700       2100

62           196         109         90           146

64           203         82           100         150

Describe how you would manage her insulin medications to improve her BS control                                       

Question 10        Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:

Significant History

Type 2 DM x 4 years, HTN

Medications

Lisinopril 10 mg daily

Metformin 1000 mg po daily

Glipizide 5 mg po daily

Physical Exam

Pale, lethargic gentleman

Skin is very dry

VS  94/64   P 112  RR 30  T  99.4   wt 195 pounds  ht 5’11 »

Lungs clear bilaterally, rapid respiration

CV :   RRR, no murmurs or gallops

Abd:  soft, non-tender, positive bowel sounds

Labs:

Hb  146    Hct  58%   Cr  4.9   Bun  53    Cholesterol  238

Na  126  K  5.6  CL 95    Ca  8.8   Gluc 722  Phosphorus 5.8

Ketone  Moderate  AST  248  Alk Phos  132

ABG’s

             ph  7.01

             Pco2  20

             Po2  100

             Sat    98% (on room air)

             HCO3   7.5

What is the anion gap? What does this mean and how would it impact your treatment plan for this patient?