Exam 2 case studies

Every 2 min until her blood pressure is stabilized

How frequently should you check Mrs. Campbell's' blood pressure while she is on the norepinephrine therapy?

Salmeterol + fluticasone should not be used as a rescue inhaler. Salmterol + fluticasone may mask the symptoms of an infection.

What patient teaching will you provide Mr. Walsh about salmeterol + fluticasone? Select all that apply.

Respiratory depression

What side effect of morphine do you need to monitor for closely while Mr. Bryant is in the ED?

to constrict blood vessels

After 1 hour of fluid and electrolyte replacement therapy, Mrs. Campbell's' vital signs are T 99.6°F, P 97, R 17, and BP 74/41. Therefore, the physician prescribes norepinephrine, 8 mcg/min in D5/NS. What is the purpose of norepinephrine?

Increase oxygen flow to 6L/min Consult with the provider about other medications to administer

After 15 minutes of treatment with the nebulizer, you re-assess Mr. Walsh's vital signs as well as his lung functions tests, which have the following results: FEV1: 2.0 L (predicted 4.1 L; 48.8%) FVC: 3.9 L (predicted 5.2 L; 75.0%) PEF: 238 L/min (predicted 643 L/min; 37.0%) FEV1/FVC: 51.3% SpO2: 86% What steps should you take next?

Take medication with food or milk. Medication may increase risk of hyperglycemia; blood glucose should be monitored carefully. Avoid use of salt substitutes. Do not take medication after 3 pm.

After 8 minutes of norepinephrine therapy, Mrs. Campbell's blood pressure stabilizes at 118/74. Her peripheral edema is now at 1+ pitting, and her pulmonary edema has resolved. The physician prescribes hydrochlorothiazide in combination with spironolactone (Aldactazide, 50 mg/50 mg bid PO). What client teaching, related to her new medications, do you need to provide to Mrs. Campbell before discharge?

Administration of tenecteplase, 50 mg IV bolus

After a brief assessment and client history, you consult with the physician. What is the priority intervention for Mr. Bryant right now?

hypovolemia

After three doses of furosemide, Mrs. Campbell once again gets up to go to the bathroom. As she stands up, she wavers and collapses. You take her vital signs, which are T 99.8°F, P 106, R 18, and BP 61/38. Syncope and low BP are signs of what condition?

Other vital signs Skin temperature and color mental status

In addition to blood pressure, what other assessments do you need to perform regularly until Mrs. Campbell is stabilized?

diazepam

It is currently 2330, and Mr. Bryant is very restless. He states that he feels tired but his anxiety about the day and his medical condition isn't allowing him to sleep. He denies the presence of chest pain, rating his pain on a 0 on a scale of 0 to 10, even though morphine has been discontinued. Which of the following medications may benefit Mr. Bryant?

aPTT should be monitored every 4-6 h, with a goal of 1.5-2 times baseline.

Mr. Bryant is now on IV heparin. What test needs to be performed regularly to monitor heparin effectiveness?

replace potassium

Mrs. Campbell's newest lab results indicate a serum sodium level of 134 mEq/L; a serum potassium level of 2.4 mEq/L; and a serum magnesium level of 1.8 mg/dL. What is the most urgent treatment for Mrs. Campbell at this time?

Mr. Bryant should be recommended for percutaneous transluminal coronary angioplasty (PTCA).

Ninety minutes after initiation of fibrinolytic therapy, Mr. Bryant's ST segment resolution is <50%. What should be the priority recommendation?

Albuterol overdose

Now that Mr. Walsh is on his nebulizer treatment, you would like to evaluate his other symptoms. What is one potential cause of Mr. Walsh's complaints of headache, sore throat, and palpitations?

Apical pulse Blood pressure

Upon recovery from angioplasty, Mr. Bryant's physician orders administration of metoprolol, 50 mg PO bid. What assessments do you need to perform before administering this medication to Mr. Bryant?

IV for heparin and PO for clopidogrel

The physician orders administration of anticoagulants for Mr. Bryant, including unfractionated heparin and clopidogrel. Which methods of administration will you need to prepare for?

serum potassium level

The physician prescribed furosemide for Mrs. Campbell. Which lab value do you need to obtain and evaluate before administering furosemide?

Administer 0.5 g methylprednisolone in 2 mL isotonic saline solution by IV injection.

The provider has ordered you to administer methylprednisolone (Solu-Medrol) via IV injection. Which dosing instructions would prompt you to double check the instructions with the provider?

Risk for Infection

Thirty minutes after methylprednisolone administration, you again check Mr. Walsh's pulmonary function tests. The results are: FEV1: 2.9 L (predicted 4.1 L; 70.7%) FVC: 4.5 L (predicted 5.2 L; 86.5%) PEF: 427 L/min (predicted 643 L/min; 66.4%) FEV1/FVC: 64.4% SpO2: 92% Although Mr. Walsh still has reduced pulmonary function, his breathing is less labored. The provider plans to admit Mr. Walsh for observation and continued medication administration. He also plans to add salmeterol + fluticasone (Advair Diskus 250/50) to Mr. Walsh's maintenance drug regimen at a dose of 1 puff twice daily. What risk diagnosis is appropriate for Mr. Walsh based on his new medication regimen?

Administer lidocaine, 100 mg IV bolus at 25 mg/min, then begin 2 mg/min infusion in D5W.

Throughout treatment, you have been monitoring Mr. Bryant's heart rhythm. One hour after Mr. Bryant arrives, he develops a dysrhythmia. What is your priority nursing intervention in this situation? Assume the physician has given contingent orders for any medications.

FEV1 (Forced Expiratory Volume, 1 sec) FVC (Forced Vital Capacity) PEF (Peak Expiratory Flow)

To address the patient's dyspnea, the provider has ordered 500 mcg (1 vial of 0.02% solution) ipratropium (Atrovent) via nebulizer. Based on provider orders, which tests will you need to administer to monitor drug effectiveness?

asthma? congestive heart failure?

What comorbidity would be a contraindication for beta blocker use?

Anticholinergic drug that causes bronchodilation of airway smooth muscles.

What drug class is ipratropium, and what is its mechanism of action?

When was the last time you took a dose of albuterol? How many puffs of albuterol do you take daily on average?

What important question(s) should you ask Mr. Walsh about his albuterol use before you administer additional medications?

Opioid antagonist

What is the mechanism of action of naloxone?

Loop of Henle

What part of the nephron does furosemide affect?

IV

When considering Mrs. Campbell's' condition, which route of administration do you need to prepare for when following the physician's orders to administer furosemide?

dyspnea

Which of Mr. Walsh's symptoms is most important to address first?

von Willebrand disease

Which of the following medical conditions would be a contraindication for fibrinolytic therapy?

3.5 L/min oxygen via nasal cannula 0.8 mg/h morphine, IV in normal saline

Which of the following medications that the EMTs administered should be administered again or continued to be administered in the emergency department?

Administration of norepinephrine during hypovolemia could cause circulatory collapse.

Why did the physician wait to prescribe norepinephrine until 1 hour after fluid therapy had started rather than from the start of fluid replacement therapy?

Mr. Walsh was already taking a short-acting beta adrenergic agonist without success.

Why would the provider have chosen to prescribe an anticholinergic drug for Mr. Walsh rather than a short-acting beta adrenergic agonist?

During drug administration, keep lips sealed around mouthpiece. Breathe deeply and slowly through your mouth. Rinse your mouth after the treatment is complete.

You are now preparing to administer ipratropium via mouthpiece. What patient teaching is important for you to provide?

Place a 22-gauge needle in the cephalic vein of his non-dominant arm

You confirm with the provider that you should immediately administer 125 mg methylprednisolone in 2 mL isotonic saline solution. You are preparing to insert the IV for the injection. Which is the best choice for the IV for Mr. Walsh?

Corticosteroid

You decide to increase Mr. Walsh's oxygen flow to 6 L/min and consult his provider about additional medications to administer. When you discuss Mr. Walsh's condition with the provider, what drug class would you anticipate him ordering?

Not(Administer 125 mcg ipratropium PO up to 500 mcg as needed)

You have been monitoring Mr. Bryant's vital signs since he arrived at the ED. His latest vital signs are T 100.3°F, P 62, R 5, and BP 102/68. Mr. Bryant appears lethargic and does not respond to commands. What is your priority nursing intervention?

Fluid output Electrolyte levels

You have begun IV furosemide treatment for Mrs. Campbell at 20 mg over 1 min. You have been instructed to repeat this dosage every hour until edema is resolved. Which of the following do you need to monitor between each dosage?