David Stahl, Daniel Johnson, and Edward Bittner
1. A 78-year-old otherwise-healthy woman arrives in the postanesthesia care unit after an urgent cystoscopy and ureteral stent placement for an impacted ureteral stone. In the operating room, there were no complications and only minimal blood loss. One hour later, she is febrile to 102.3°F, tachycardic with a heart rate of 117 bpm, and hypotensive with a noninvasive blood pressure of 73/42 mm Hg. Blood cultures are drawn and broad-spectrum antibiotics are initiated. A central venous catheter is placed, and the central venous pressure is measured at 2 mm Hg. The best next step in the management of her shock is
A. Start dobutamine for increased inotropy
B. Fluid resuscitation to restore adequate preload
C. Blood transfusion to a goal hemoglobin concentration of 12 g/dL
D. Initiate nitroglycerin infusion to off-load the right ventricle
2. Shock is most accurately defined as
A. Inadequate tissue perfusion to meet the oxygen demand of end organs
B. Hypotension not responsive to intravenous fluid administration
C. An irreversible process of multisystem organ failure
D. Decreased blood flow resulting from inadequate cardiac output
3. A 73-year-old man with a history of chronic obstructive pulmonary disease (COPD) on home oxygen was initially admitted to the medical floor for a COPD exacerbation. Over the past few hours, he has developed altered mental status and hypotension. He is transferred to the ICU, intubated, and vasopressors are started to support his blood pressure. A pulmonary artery catheter is placed via the right internal jugular vein. Initial readings reveal central venous pressure = 23 mm Hg, positive airway pressure = 34/15 mm Hg, pulmonary capillary wedge pressure = 4 mm Hg, and CO = 1.9 L/min. The most likely diagnosis is
A. Hypovolemic shock from inadequate fluid resuscitation
B. Septic shock from pneumonia
C. Anaphylactic shock from medications given during intubation
D. Cardiogenic shock from right-ventricular failure
4. A 54-year-old man is postoperative day 1 after a pancreaticoduodenectomy for pancreatic cancer, complicated by a small intraoperative bile leak. He is febrile to 39.5°C, rigorous, and hypotensive with a blood pressure of 71/32 mm Hg. He is admitted to the ICU. Laboratory work reveals a leukocytosis with bandemia. Despite 4 L of intravenous crystalloid, he remains hypotensive. The most accurate diagnosis for his condition is
A. Postoperative infection
B. Sepsis
C. Severe sepsis
D. Septic shock
5. Dopamine acts on all of the following receptors, except
A. α1
B. β1
C. β2
D. DA1
6. All of the following may be caused by β-agonist effects of vasopressors, except
A. Increased inotropy
B. Bronchodilation
C. Inhibition of renin secretion
D. Uterine relaxation
7. You are called to the ER to assist in the intubation and management of a 26-year-old man who sustained significant closed head injury during a motorcycle collision. Following uneventful intubation, you accompany the patient and neurosurgery team to the CT scanner where you see a large subarachnoid hemorrhage with effacement of the sulci and 9-mm midline shift. While preparations are made to proceed directly to the operating room, the neurosurgeon asks if you can increase the patient’s mean arterial blood pressure (MAP) from 70 to 90 mm Hg to improve cerebral perfusion. The best vasopressor to accomplish this increase in MAP is
A. Dopamine
B. Phenylephrine
C. Norepinephrine
D. Epinephrine
8. Acute renal failure is defined as
A. Urine output of less than 0.5 mL/kg/hr or increase in serum creatinine by 50% in 24 hours
B. Urine output of less than 1 mL/kg/hr or increase in serum creatinine by 100% in 24 hours
C. Urine output of less than 1 mL/kg/hr or increase in serum creatinine by 200% in 24 hours
D. Urine output of less than 0.25 mL/kg/hr or increase in serum creatinine by 50% in 24 hours
9. A 28-year-old man is admitted to the intensive care unit after a motorcycle collision from which he suffers multiple injuries including traumatic aortic injury requiring open repair, multiple long-bone fractures, and a closed head injury. On arrival, his blood pressure is maintained on a norepinephrine infusion. His urine output has been <5 mL/hr for the past 8 hours despite adequate fluid resuscitation and a renal ultrasound study that was normal. His pH on arterial blood gas analysis is 6.9 with a base deficit of 16 and a potassium of 5.4 mEq/L. The decision is made to institute renal replacement therapy for recalcitrant acidosis. The best course of action is
A. Institution of continuous renal replacement therapy (CRRT) as it has been shown to improve mortality at 30 days when compared to intermittent hemodialysis (IHD)
B. Institution of IHD as it has been shown to improve in-hospital mortality when compared to CRRT
C. Institution of IHD as it has been shown to more effectively clear acidosis
D. Institution of CRRT as it has been shown to be more hemodynamically stable than IHD
10. Delirium as defined by the DSM-IV includes which of the following major tenants?
A. Decreased attention and altered cognition
B. Agitation and pulling at lines
C. Altered mental status and dementia
D. Chronic perceptual disturbances and depressed mood
11. Delirium in the ICU setting is
A. A relatively benign condition
B. Associated with increased mortality
C. Associated with a decreased risk of eventual development of dementia
D. Often successfully treated with benzodiazepines
12. An 88-year-old man is admitted to the intensive care unit after a right-hip hemiarthroplasty to repair an intertrochanteric femur fracture sustained during a fall from standing. On postoperative day 1, he is confused and intermittently agitated with a disorganized thought process. His nurse completed the CAM-ICU screen and reports that the result was positive. The next steps in the management should include all of the following, except
A. Continually reorienting the patient to his surroundings
B. Minimizing sedatives if possible
C. Removing all opioids from his pain regimen
D. Optimizing sleep health by minimizing nighttime wakeups and encouraging daily wakefulness
13. All of the following conditions are associated with delirium in the ICU, except
A. Advanced age
B. Orthopedic surgery
C. Sepsis
D. Sleep deprivation
14. Which of the following is a benefit of enteral nutrition when compared to parenteral nutrition?
A. Decreased cost
B. Decreased length of mechanical ventilation
C. Decreased rates of infection
D. All of the above are benefits of enteral nutrition
15. Enteral nutrition should be initially avoided in a
A. 54-year-old man who presents with acute alcoholic pancreatitis
B. 23-year-old G1P0 with hyperemesis gravidarum
C. 76-year-old woman with a full-thickness esophageal perforation
D. 34-year-old woman hospitalized with an acute exacerbation of ulcerative colitis
16. A 36-year-old G3, now P3, after a normal spontaneous vaginal delivery is complicated by postpartum hemorrhage. Her vitals are checked, and she is noted to be tachycardic with a HR of 132 bpm and hypotensive with a BP of 76/35 mm Hg. The rapid response team is called. As a result of calling the rapid response team, which of the following outcomes can most reasonably be expected?
A. She is less likely to have a cardiopulmonary arrest on the postpartum floor
B. She is less likely to have a cardiopulmonary arrest in the hospital
C. She is less likely to be transferred to an ICU
D. She is more likely to survive to hospital discharge
17. The most significant risk of intensive insulin therapy (goal blood glucose 80–100 mg/dL) when compared to moderate glucose control (goal blood glucose <180 mg/dL) is
A. Myocardial infarction
B. Seizure
C. Patient dissatisfaction
D. Hypoglycemia
18. A 54-year-old man is admitted to the intensive care unit for monitoring after a complicated left colectomy for diverticulitis. He has a history of type 2 diabetes mellitus on metformin. On arrival to the ICU, his blood glucose on an arterial blood gas is 254 mg/dL. One hour later, it is 435 mg/dL. The next appropriate step in his management is
A. Recheck blood glucose in 1 hour
B. Restart home metformin
C. Start IV insulin therapy with a goal glucose <180 mg/dL
D. Start IV insulin therapy with a goal glucose <120 mg/dL
19. A 93-year-old woman is admitted to the ICU with a leaking 7.8-cm abdominal aortic aneurysm. A multidisciplinary discussion is initiated between the patient, family, bedside nurse, ICU team, and surgery team to decide on the next course of action. Select the answer which best identifies the ethical principle at hand in each quote:
A. Autonomy—patient: “I accept that refusing an operation means I will likely die soon, but I want to die at home with my family around me if at all possible”
B. Beneficence—ICU attending: “I worry that if you have this operation it will be unlikely that you will ever return to living at home without significant assistance”
C. Nonmaleficence—surgeon: “The best chance of you surviving is to have the aneurysm repaired”
D. Justice—patient’s daughter: “Is there another way to do the operation that is less risky?”
20. An 86-year-old man with end-stage congestive heart failure and chronic obstructive pulmonary disease is admitted to the intensive care unit after a fall down one flight of stairs from which he sustains a large subarachnoid hemorrhage. After lengthy discussion with the family, including the patient’s wife who has been previously designated his health-care proxy, a decision is made to change goals of care to comfort measures alone. The patient is started on a morphine infusion for pain and to control dyspnea; he is extubated and the family is present at the bedside. About an hour later, the patient’s daughter emerges from the room, and tearfully asks, “How much longer can this go on? Can’t you do something to speed up the process?” You correctly reply
A. “We can add additional sedation which will make him pass more quickly”
B. “I can give him a bolus of morphine to stop him from breathing”
C. “We can increase the rate of the morphine infusion if he appears to be in pain”
D. “We can give him a strong muscle relaxant called rocuronium, which will stop him from breathing”
21. An 89-year-old woman is postoperative day 23 from an open repair of a thoracoabdominal aortic aneurysm. She is bacteremic for a second time, and continues to require vasopressor support, mechanical ventilation, and continuous renal replacement therapy. After the most recent of many multidisciplinary family meetings, the decision is made to withdraw life-sustaining treatment and focus on comfort measures alone. As you are discussing with the bedside nurse the logistics of removing vasopressor support, a nursing student asks, “Isn’t that going to kill her?” The most correct response is
A. “Since our goal is not to end her life, it is not technically killing her”
B. “As long as her heart beats after we turn off the medications, it is not euthanasia”
C. “As long as the family has given us permission it is OK”
D. “Stopping these treatments simply discontinues our prolongation of her natural death”
22. A 45-year-old construction worker falls from a three-story building suffers multiple traumatic injuries including a partial amputation of his left leg, resulting in substantial hemorrhage. He is admitted to the intensive care unit directly from the emergency room having received 4 U of packed red blood cells and 2 U of fresh-frozen plasma. Following further resuscitation and operative repair of his left leg, his serum creatinine is noted to be 2.13 mg/dL, and urine output is 0.3 mL/kg/h. The most likely etiology of his renal failure is
A. Prerenal failure from hypotension
B. Prerenal failure from thromboembolic disease
C. Intrinsic renal failure from rhabdomyolysis
D. Postrenal failure from ureteral obstruction
23. A 28-year-old woman with a history of Hodgkin lymphoma and external beam radiation is admitted to the intensive care unit after repair of an esophageal perforation. She is maintained strictly NPO. Addition of dextrose to her maintenance intravenous fluids will most likely
A. Fail to suppress protein catabolism
B. Improve her blood glucose control
C. Increase her insulin requirement
D. Improve her cardiac metabolic balance
24. Which of the following tissues does not rely on glucose metabolism in the setting of starvation?
A. Neural tissue
B. Cardiac tissue
C. Renal medullary tissue
D. Erythrocytes
25. Which of the following parenteral nutrition orders would be least likely to precipitate hypercarbic respiratory failure in a patient with severe chronic obstructive pulmonary disease?
A. Protein = 40 g/L, dextrose = 125 g/L, fat = 0 g/L
B. Protein = 30 g/L, dextrose = 150 g/L, fat = 0 g/L
C. Protein = 50 g/L, dextrose = 60 g/L, fat = 50 g/L
D. Protein = 50 g/L, dextrose = 100 g/L, fat = 25 g/L
26. A 25-year-old man is admitted to the intensive care unit after exploratory laparotomy and repair of multiple bowel injuries from several gunshot wounds. Several hours after admission, the respiratory therapist calls to alert you that his peak airway pressures have increased significantly. The bedside nurse also reports an increase in his vasopressor requirement, and a decrease in urine output. On examination, his abdomen is tense, with a midline dressing intact, and clear breath sounds bilaterally. The most likely diagnosis is
A. Acute myocardial infarction leading to pulmonary edema
B. Hypovolemia from inadequate fluid resuscitation
C. Hemorrhage from an unrecognized injury
D. Abdominal compartment syndrome from bowel edema or hemorrhage
27. One of the feared adverse effects of reinstituting nutrition in a malnourished patient is refeeding syndrome. The most common electrolyte abnormality seen in refeeding syndrome is
A. Hypophosphatemia from an increase in intracellular movement of phosphate
B. Hypokalemia from extracellular buffering of alkalosis
C. Hypomagnesemia from renal losses
D. Hyponatremia from excess free water retention by the kidney
28. A 59-year-old man with acute chronic pancreatitis complicated by pseudocyst and necrotizing pancreatitis has been receiving total parenteral nutrition (TPN) for 3 weeks. An error in the ordering system prevents the pharmacy from receiving his order in time to make that day’s supply. If his TPN is abruptly discontinued, he is at highest risk for
A. Hyponatremia
B. Hypokalemia
C. Hypoglycemia
D. Hyperkalemia
29. Acute respiratory distress syndrome (ARDS) patients’ plateau pressures should be maintained at or below
A. 50 cm H2O
B. 60 cm H2O
C. 40 cm H2O
D. 30 cm H2O
30. Helium–oxygen mixtures can be useful therapies for patients with upper airway obstruction. Compared with air, helium–oxygen mixtures have lower
A. Density
B. Viscosity
C. Oxygen content
D. Nitrous oxide content
31. In assist-control ventilation (ACV)
A. Breaths triggered by the ventilator result in the full preset tidal volume being delivered, while breaths triggered by the patient are unsupported by the ventilator
B. All breaths result in the full preset tidal volume being delivered, regardless of whether they are initiated by the ventilator or by the patient
C. All breaths must be initiated by the patient
D. The patient is incapable of triggering breaths
32. A 78-year-old man is admitted from the surgical floor to the intensive care unit for respiratory distress. He is postoperative day 1 from open reduction and internal fixation of a right femoral shaft fracture sustained during a motor vehicle collision. His heart rate is 118 bpm, blood pressure is 104/62 mm Hg, SpO2 is 68% on a non-rebreathing mask at 15 L/min of oxygen, and respirations are 42/min. On examination, he is unresponsive to commands and to sternal rub. The ICU team is deciding whether to initiate noninvasive positive-pressure ventilation (NIPPV) or to perform endotracheal intubation. NIPPV is contraindicated because
A. The patient’s neurologic examination suggests that he is incapable of protecting his airway
B. NIPPV is incapable of improving significantly low oxygen saturations
C. The patient is claustrophobic
D. The patient has certainly suffered a pulmonary embolism (PE), and NIPPV is not helpful in this situation
33. In the first several days following traumatic brain injury requiring mechanical ventilation, an optimal regimen for anxiolysis includes
A. Diazepam bolus every hour
B. Lorazepam infusion
C. Hydromorphone infusion
D. Propofol infusion
34. In pressure-support ventilation (PSV), inspiration ends (and expiration begins) when
A. A preset tidal volume has been achieved
B. A preset airway pressure has been achieved
C. Flow decreases to a preset level
D. A preset amount of time has passed
35. A patient can be diagnosed with acute respiratory distress syndrome (ARDS) if he or she has an acute onset of illness, bilateral infiltrates on chest X-ray, lack of evidence of left heart failure, and a PaO2/FIO2 (P/F) ratio of less than or equal to
A. 500 mm Hg
B. 400 mm Hg
C. 350 mm Hg
D. 200 mm Hg
36. A 25-year-old woman has been in the ICU for 6 days after sustaining multiple life-threatening traumatic injuries. She is suffering from septic shock and acute respiratory distress syndrome (ARDS). On examination, she is dyssynchronous with the ventilator, coughing, grimacing in pain, and tearful. SpO2 is 88% on a FIO2 of 100%, and the BP is 108/58 mm Hg on a low-dose infusion of norepinephrine. The most appropriate plan for management of the patient’s pain, anxiety, and ventilator dyssynchrony is
A. Hydromorphone PRN and a continuous infusion of cisatracurium
B. Fentanyl infusion and a continuous infusion of cisatracurium
C. Midazolam and fentanyl infusions
D. Lorazepam PRN
37. A patient is at greatest risk for requiring endotracheal intubation and mechanical ventilation if the SpO2 is 91% while breathing
A. Room air
B. 4 L/min of oxygen via nasal cannula
C. 15 L/min of oxygen via a non-rebreathing mask with reservoir bag
D. Noninvasive positive-pressure ventilation with an FIO2 of 35%
38. Weaning from mechanical ventilation is expedited by
A. Daily spontaneous breathing trials
B. Synchronized intermittent mandatory ventilation (SIMV)
C. Administration of bronchodilating medications around the clock
D. Daily bronchoscopy
39. Synchronized intermittent mandatory ventilation (SIMV) was an improvement on intermittent mandatory ventilation (IMV) because it
A. Can provide full ventilation support to an apneic patient
B. Can utilize volume-preset or pressure-preset ventilation
C. Allows the patient to breathe spontaneously
D. Reduces the likelihood of breath stacking and volutrauma
40. Tracheostomy should be considered to reduce the risk of subglottic stenosis after an endotracheal tube has been in place for
A. 5 days
B. 10 days
C. 2 to 3 weeks
D. 8 to 10 weeks
41. A 45-year-old alcoholic male was admitted to the medical floor with severe pancreatitis. On hospital day 5, his respiratory status significantly deteriorates and he is transferred to the ICU. The SpO2 is 89% on a non-rebreather mask at 15 L/min oxygen. Upon arrival in the ICU, he is sedated and intubated. Initial ventilator settings should include a set tidal volume of
A. 2 mL/kg
B. 6 mL/kg
C. 10 mL/kg
D. 14 mL/kg
42. A 20-year-old trauma patient requires a large dose infusion of propofol while intubated in the ICU. When the propofol is reduced to attempt a spontaneous breathing trial, the patient thrashes wildly and tries to pull out his arterial and central venous lines. A titratable agent that could prove useful for management of this patient’s agitation while not depressing his respiratory drive is
A. Methadone
B. Dexmedetomidine
C. Nitrous oxide
D. Fentanyl transdermal patch
43. For pressure-preset ventilation (also known as “pressure-control ventilation”), the independent variable and dependent variable, respectively, are
A. Tidal volume and FIO2
B. Tidal volume and frequency
C. SpO2 and airway pressure
D. Airway pressure and tidal volume
44. A mechanically ventilated, 70-kg patient has an arterial blood gas of pH = 7.06, PCO2 = 83 mm Hg, and PO2 = 140 mm Hg on volume control ventilation (tidal volume = 450 mL, respiratory rate = 8, FIO2 = 50%, and positive end-expiratory pressure [PEEP] = 8 cm H2O). The most appropriate next step in the management is
A. Increase PEEP
B. Increase FIO2
C. Increase the respiratory rate
D. Administer sodium bicarbonate
45. The primary benefit of positive end-expiratory pressure (PEEP) during mechanical ventilation is
A. Improved elimination of CO2
B. Improved venous return and cardiac output
C. Prevention and reversal of alveolar collapse (atelectasis)
D. Reduction in peak inspiratory pressure
46. A patient with a chronic obstructive pulmonary disease exacerbation has an initial arterial blood gas (ABG) with pH = 7.05, PCO2 = 95 mm Hg, and PO2 = 54 mm Hg on 6 L of oxygen via nasal cannula. The patient is awake, alert, and in moderate respiratory distress with significant wheezing. Bronchodilators and continuous positive airway pressure (CPAP) 10 cm H2O via face mask with FIO2 of 50% are initiated. One hour later, the ABG is pH = 7.10, PCO2 = 90 mm Hg, and PO2 = 92 mm Hg. The patient remains awake and alert and is now in less distress. The most appropriate next step in the management is
A. Increasing the FIO2
B. Increasing CPAP to 15 cm H2O
C. Changing the mode to bi-level positive airway pressure (BiPAP)
D. Stopping CPAP and delivering oxygen via high-flow nasal cannula
47. An ICU patient with severe acute respiratory distress syndrome (ARDS) remains dyssynchronous with the ventilator despite administration of high-dose propofol and fentanyl infusions and changes in the mode of ventilation. The patient’s gas exchange has deteriorated over the course of the day, and hypotension requiring vasopressor support has developed in the setting of increasing the propofol dose. The next best step is to
A. Increase propofol
B. Change to pressure-support ventilation
C. Aggressively diurese the patient
D. Administer a nondepolarizing neuromuscular-blocking agent
48. A 35-year-old man is receiving care in the ICU after sustaining an 80% total body surface area burn from a house fire 5 weeks ago. The surgical team wishes to transition from large dressing changes in the operating room to smaller dressing changes in the ICU. The patient’s analgesic regimen consists of extended-release morphine 60 mg by mouth every 12 hours and hydromorphone 2 to 4 mg IV every 2 hours PRN for breakthrough pain. The most appropriate agent for providing sedation and analgesia during the dressing changes in the ICU is
A. Oral gabapentin
B. Oral clonidine
C. Intravenous morphine
D. Intravenous ketamine
49. A 30-year-old man is admitted to the ICU intubated after a 14-hour spine surgery in the prone position. When he emerges from anesthesia, he bites down on his endotracheal tube, tries frantically to breathe, and panics when he is unable to draw a breath. The nurse boluses propofol and achieves adequate sedation. Five minutes later, the SpO2 rapidly falls from 99% to 65% and the patient appears cyanotic. Pink froth is seen in the endotracheal tube. This complication could have been avoided by
A. Placing a bite block between the patient’s teeth
B. Administration of less IV fluid during the spine surgery
C. Omitting the propofol bolus
D. Positioning the patient in reverse Trendelenburg
50. Effective treatment for carboxyhemoglobinemia includes
A. Sodium nitrite
B. Ventilation with 100% oxygen
C. Ventilation with air
D. Sodium thiosulfate
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