MS4 Exam 3

QSEN: Care of pt with dysrhythmias

-Assess vitals q4hr or more -Cardiac monitor -Monitor electrolytes & heart enzymes -Assess pt's subjective data -Assess peripheral perfusion -Administer anti-dysrhythmic as prescribed & evaluate outcome -Observe for SOB -Promote stress reduction

Normal PR measurement

-Atrial depolarization (contraction) -0.12 - 0.20 seconds (3-5 small boxes)

Permanent pacemaker pt teaching

-Avoid electromagnetic fields (MRIs, transmitter towers for tvs (home tvs do not matter)) -Carry pacemaker ID card -Take pulse for 1 min at same time daily for diary -Do not apply pressure over it (loose clothing) -If feeling symptoms when near a new device step away 5-10 ft to feel relief -Report: dyspnea, dizziness, syncope, chest pain, weight gain, prolonged hiccups to HCP -Follow activity restriction after placement, usually about 8 weeks

Foods/bevs/drugs to avoid if taking Warfarin

-Broccoli -Cauliflower -Spinach -Kale -Brussel sprouts -Beef liver -Parsley -Soybeans -Cranberry juice -Allopurinol (for gout) -NSAIDs & Acetaminophen -Oral contraceptives -Antibiotics -Antidepressants -Antifungals -Thyroid drugs

S/S of Sinus Tachycardia

-Fatigue -Weakness -SOB -decreased SaO2 -increased pulse rate -decreased bp -may be restless too

S/S of sinus bradycardia

-Likely asymptomatic -syncope -dizziness/weakness -confusion -hypotension -diaphoresis -SOB -chest pain

Atrial Fibrillation (AF/Afib)

-MOST COMMON dysrhythmia -Causes clotting -CHAOTIC, "saw tooth", wavy rhythm -Diagnose w/ 12 lead ECG -Treat w/ anticoagulants b/c HIGH PE RISK -Uncoordinated atrial contractions can lead to blood pooling then PE S/S: May be asymptomatic Irregular pulse Poor peripheral perfusion Fatigue Syncope Palpitations Chest discomfort Hypotension

Post permanent pacemaker placement assessment

-Monitot ECG rhythm -Assess site for bleeding, swelling, redness, infection -Dressing should be clean & dry -Will have activity restrictions that HCP slowly lifts (usually 8 weeks) -Monitor for changes in vitals that could indicate cardiac tamponade, pleural effusion, etc.

What are the expected findings in a client ARDS?

-Pa02 of 45 on 100% fiO2 (refractory hypoxemia), -PAWP of more than 15 -Decreased pulmonary compliance -Dense pulmonary infiltrates on chest x-ray study (white lungs)

Anticoagulant pt teaching

-Used to stabilize/stop growth of existing clots AND prevent new clots -Fall precautions -Avoid foods high in vitamin K (if taking warfarin) -Apply ice to trauma -Use soft toothbrush -Use stool softener -Avoid blowing nose -No anal, rectal temps, or lifting -Use electric razor only

Normal QRS complex

-Ventricular depolarization (contraction) -0.04 - 0.12 seconds (1-3 small boxes)

Atropine

-given for BRADYCARDIA -monitor HR & rhythm -increased HR expected/desired

Beta blockers for dysrythmias

-lols -monitor HR & BP -monitor for wheezing, SOB, fatigue -do not give to pts w/ preexisting respiratory disorders (asthma, COPD)

Adenosine

-used for paroxysmal SVT (supra-ventricular tachycardia) -push over 8-10 -heart will stop/flatline for about 15 seconds then restart -have emergency equipment bedside

P Wave

1st wave of ECG representing the contraction (depolarization) of the atria should be about 0.12-0.20 seconds long

QRS Interval

2nd wave of ECG representing the contraction (depolarization) of the ventricle should be about 0.06-0.10 seconds long

How to calculate MAP

2x diastolic (bottom #) + systolic (top #) all divided by 3

Normal potassium level

3.5-5

What ECG changes and patterns are diagnostic of a myocardial infarction?

Abnormal Q waves and a ST segment elevation

Premature complexes

Early rhythm that occurs before it is expected Usually described as palpitations, can happen in a healthy or unhealthy heart, if consistent pt may experience decreased CO

Electrical cardioversion

Electrical shock given to restore/regulate HR for pt w/ new onset Afib If Afib is more than 48 hours from onset, pt must take anticoagulants for 3 weeks prior to this procedure Safety: turn off & remove O2 therapy from pt before to prevent fire, yell CLEAR before giving shock Aftermath: Maintain airway Give O2 Assess vitals & LOC Monitor for Afib Assess skin that was shocked for burn Administer anti-dysrhythmic as prescribed

Supra ventricular Tachycardia (SVT)

Episodes of abnormally fast/racing heartbeat 100-280 BPM -Vagal maneuvers to treat (squatting, valsava maneuver, carotid massage done by HCP only) -Treat w/ Adenosine if does not resolve on its own Can occur in healthy people (esp. women)

SA Node

Located on the surface of the right atrium, begins the process of the heart rate, aka pacemaker

MONA for suspected MI

Morphine Oxygen Nitroglycerin Aspirin

Synchronous (demand) pacing

Pacemaker is set to work w/ pt's own beats If natural HR too high, pacemaker will not fire If natural HR too low, pacemaker will fire Other option is asynchronous pacing which is a fixed rate & not the preferred type of pacing

Automaticity of QRS Interval

Should be 0.06-0.10 seconds (About twice the P wave)

Automaticity of P Wave

Should be 0.12-0.20 seconds

Transcutaneous Pacing

Temporary pacemaker used for emergencies before a permanent pacemaker can be placed Used for profoundly bradycardic or asystolic pts Can be painful on skin, likely will give pain meds

When evaluating the effectiveness of preoperative teaching with a client scheduled for coronary artery bypass graft surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the client say which of the following? a. "I will have small incisions in my leg where they will remove the vein" b. "They will use an artery near my heart to go around the area that is blocked" c. "They will circulate my blood with a machine during the surgery" d. "I will need to take an aspirin every day after the surgery to keep the graft open"

a. "I will have small incisions in my leg where they will remove the vein" -Additional teaching to let pt know it will be done near mammary (breast)tissue -Other statements are accurate

A nurse is teaching a group of nursing students about antidysrhythmic medications. Which statement by a student indicates understanding of the teaching? a. "​Antidysrhythmic drugs can cause new dysrhythmias or worsen existing ones​" b. "Adverse effects of these drugs are mainly noncardiac in nature" c. "For all antidysrhythmic drugs, there is evidence of reduced mortality" d. "Use of these drugs may be necessary even if the benefits are unknown"

a. "​Antidysrhythmic drugs can cause new dysrhythmias or worsen existing ones​" #1 adverse effectof antidysrhythmic drugs is the creation of another dysrhythmia

A client who is taking warfarin therapy has a mild headache rated at a 2 out of 10 scale and calls the HCP to ask about taking a pain reliever. The nurse expects to receive instructions for which type of medication? a. Acetaminophen b. Morphine c. Ibuprofen d. Aspirin tablets

a. Acetaminophen

The nurse is caring for a client with a pulmonary embolus who also has developed right sided heart failure. Which symptom will the nurse need to report immediately to the health care provider? a. Blood pressure of 88/45 mmHg b. Dry cough c. Heart rate of 105 beats/min d. Respiratory rate of 24 breaths/min

a. Blood pressure of 88/45 mmHg

A 50-year-old client is admitted for acute myocardial infarction. Troponin T and I are positive on admission as well as ST elevation and T wave inversion. While preparing to transport the client for percutaneous coronary intervention which of the following must be reported promptly to the provider? a. Chest pain lasting 30 minutes or more b. Pain or discomfort in jaw, back, shoulder or abdomen c. New onset of premature ventricular contractions d. Feelings of fear and anxiety

a. Chest pain lasting 30 minutes or more or C

The nurse is assessing a client with septic shock who is intubated and mechanically ventilated. Which assessment would cue the nurse to the potential of ARDS development? a. Client now requiring high pressures to ventilate b. Normal chest radiograph with enlarged cardiac structures c. PaO2 of 20 on 45% FiO2 d. Increased pulse O2 via pulse oximetry.

a. Client now requiring high pressures to ventilate

Which client at the cardiovascular clinic requires the most immediate action by the nurse? a. Client with chronic stable angina whose chest pain has recently increased in frequency b. Client with chronic hypertension whose blood pressure today is 160/95 mmHg c. Client with familial hypercholesterolemia and a total cholesterol level of 365 mg/dL d. Client with type 2 diabetes whose current blood glucose level is 205 mg/dL

a. Client with chronic stable angina whose chest pain has recently increased in frequency

The nurse is reviewing the laboratory results for newly admitted clients on the cardiovascular unit. Which client laboratory result is most important to communicate as soon as possible to the HCP? a. Client with increase in troponin T and troponin I levels b. A client with a depressed ST segment c. A client whose triglyceride level is high d. A client who has ST segment elevation

a. Client with increase in troponin T and troponin I levels

A client is in normal sinus rhythm with consistent PR intervals of 0.21 seconds. What treatment should the nurse expect to be prescribed for this client? a. Continue to monitor b. Anticipate defibrillating c. Prepare for cardioversion d. Prepare for pacemaker insertion

a. Continue to monitor Normal PR interval is 0.12-0.20

A client with respiratory failure has a RR of 5 breaths/min and an oxygen saturation of 78% on 15 liters of O2 via a venturi mask. The client is increasingly lethargic. Which intervention will the nurse anticipate? a. Endotracheal intubation and positive pressure ventilation b. Insertion of a mini-tracheostomy with frequent suctioning c. Initiation of continuous CPAP d. Administration of 100% oxygen by non-rebreather mask

a. Endotracheal intubation and positive pressure ventilation This will increase their respirations

The nurse is discharging a client with the diagnosis of Peripheral vascular disease following peripheral artery bypass surgery. What should the nurse teach the client about footcare? a. Keep your feet clean by washing them with mild soap in room temperature water b. Initiate elevation of lower extremities at all times c. Wear only snug, pointed, not rounded, tight fitting shoes d. Use a heating pad carefully to promote vasodilation

a. Keep your feet clean by washing them with mild soap in room temperature water

The nurse is caring for a mechanically ventilated client and responds to a high pressure alarm. Recognizing common causes for the alarms, the nurses assesses for which of the following? (Select all that apply) a. Kinks in the ventilator tube b. Client biting on the ET tube c. Disconnection from the ventilation d. Spontaneous Breathing e. Indicators for suctioning

a. Kinks in the ventilator tube b. Client biting on the ET tube e. Indicators for suctioning

A client with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will anticipate taking next? a. Lower the PEEP b. Increase the tidal volume and RR c. Perform endotracheal suctioning more frequently d. Increase the function of the FI02

a. Lower the PEEP

The nurse notes that PR intervals are getting progressively longer before a QRS complex is dropped on a client's cardia rhythm strip. Which health problem should the nurse realize this client is experiencing? a. Mobitz I b. Mobitz II c. First degree AV block d. Third degree AV block

a. Mobitz I

When caring for a client with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty (cardiac catheter) via the right femoral artery. Which should be included in the plan of care? a. Monitor and document pulses distal the femoral artery b. Instruct the client to do active leg exercises an hour after the procedure c. Assess the right groin for bleeding and hematoma d. Maintain high fowlers position. e. Assess for chest pain

a. Monitor and document pulses distal the femoral artery c. Assess the right groin for bleeding and hematoma e. Assess for chest pain

A client is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the client on a heart monitor and obtains the following ECG tracing. Which action should the nurse take first? a. Obtain the clients VS include O2 saturation b. Prepare to give metoprolol to slow the HR c. Have the client perform the Valsalva maneuver d. Prepare to perform electrical cardioversion

a. Obtain the clients VS include O2 saturation

Which of the following are physiological effects of PEEP used in treatment of ARDS? (Select all that apply) a. Prevents collapse and unstable alveoli b. Open capsuled alveoli c. Decreased tidal volume delivered to the client d. Decreased functional residual capacity e. Improved arterial oxygenation

a. Prevents collapse and unstable alveoli b. Open capsuled alveoli e. Improved arterial oxygenation

A nurse is teaching a client with unifocal premature ventricular contractions. Which education should the nurse include in the clients teaching? (Select all that apply) a. Stress reduction and management b. Adverse effects of medication c. Foods high in potassium d. Avoiding vagal stimulation e. Smoking cessation. f. Medications that cause PVCs

a. Stress reduction and management c. Foods high in potassium e. Smoking cessation. Premature contractions = palpitations Also avoid caffeine & alcohol

A client's respiratory status changed and needs adjustment to the mechanical ventilator modes and settings. The pulmonologist wants the client to receive 10 breaths/min from the ventilator but wants to encourage the client to breathe spontaneously between the mechanical breaths at the client's own tidal volume. Which mode of ventilation will accomplish these goals? a. Synchronized intermittent mandatory ventilation b. Assist/control ventilation c. Controlled ventilation d. Positive end-expiratory pressure

a. Synchronized intermittent mandatory ventilation SIMV allows pt to breathe at own rate & tidal volume in between the ventilator's breaths Can be used to wean pts off mechanical ventilators

A client was admitted for acute MI and underwent percutaneous coronary intervention and stent placement 36 hours ago. After reviewing a client's history, vital signs, physical assessment, and laboratory data, which information shows below is most important for the nurse to communicate to the health care provider? a. Tachypnea and bilateral crackles b. Blood pressure of 114/58 c. Fever and hyperglycemia d. Elevated troponin levels

a. Tachypnea and bilateral crackles May indicate left-sided HF

What should a nurse include in the teaching plan for the client admitted with a diagnosis of pulmonary embolism? (Select all that apply) a. Teaching the hazards of sitting or standing for prolonged periods b. Encouraging a diet high fiber or (Administer stool softener such as Docusate Sodium) c. Restriction of ambulation during long flights d. Frequent massaging of the lower extremities e. Encourage smoking cessation

a. Teaching the hazards of sitting or standing for prolonged periods b. Encouraging a diet high fiber or (Administer stool softener such as Docusate Sodium) e. Encourage smoking cessation Also teach to: avoid crossing legs, ambulate frequently, do not do valsava maneuver

A client's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is re-taped, the nurse auscultates the client's lungs and notes that the breath sounds over the left lung are absent. The nurse suspects that this most likely is caused by which of the following? a. The ET tube is in the right mainstem bronchus b. The client has aspirated secretions during the procedure c. The client has a right pneumothorax d. The stethoscope earpiece is clogged with wax

a. The ET tube is in the right mainstream bronchus

In an effort to prevent ventilator-associated pneumonia (VAP), which actions by the RN indicate a good understanding of the established guidelines? (Select all that apply) a. The RN maintains HOB elevation at least 30 degrees b. The RN always brushes client's teeth at least every 8 hours c. The RN suctions the client every 2 hours d. Administration of esomeprazole 40 mg IV daily e. Empty ventilator tubings when moisture collects back into the cascade f. The RN drains the water that collects in the ventilator tubing away from the client g. The RN always wears gloves when in contact with the client and change gloves between activities h. The RN asks for assistance to turn the client to the prone position

a. The RN maintains HOB elevation at least 30 degrees b. The RN always brushes client's teeth at least every 8 hours d. Administration of esomeprazole 40 mg IV daily (Nexium - ulcer prophylaxis) do NOT empty it into back cascade, just empty it

The nurse is educating a client with peripheral artery disease on managing the disease at home. Which statement would be included in the teaching? a. You should avoid crossing your legs at all times b. You could use a heating pad directly over your legs to promote circulation c. You will need to quit smoking as soon as you can d. You should take your pentoxifylline and clopidogrel as prescribed e. You have to elevate your legs above the level of your heart

a. You should avoid crossing your legs at all times c. You will need to quit smoking as soon as you can d. You should take your pentoxifylline and clopidogrel as prescribed

After receiving change of shift report, which client will the nurse assess first? a. A client with cystic fibrosis who has thick, green colored sputum b. A client with septicemia who has intercostal and suprasternal retractions c. A client with emphysema who has an oxygen saturation of 91% to 92% d. A client with pneumonia who has crackles in the both lung bases

b. A client with septicemia who has intercostal and suprasternal retractions

To evaluate the effectiveness of ordered interventions for a client with ventilatory failure, which diagnostic will be most useful to the nurse? a. Central venous pressure monitoring b. Arterial blood gas monitoring c. Oxygen saturation d. Chest X-ray

b. Arterial blood gas monitoring

A prescriber has ordered treatment for a client with recurrent tachycardia with a heart rate of 148 BPM. The nurse should QUESTION which order? a. Metoprolol b. Atropine c. Adenosine d. Diltiazem

b. Atropine Atropine is used to treat bradycardia & would increase the HR more

The nurse is assessing a client with septic shock who is intubated and mechanically ventilated and an oxygen saturation of 89%. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS) development? a. Increased oxygen saturation via pulse oximetry b. Client has a trend of gradually increasing PIP over several hours over the day c. Normal chest radiograph with enlarged cardiac structures d. PaO2 of 80 on 45% FIO2

b. Client has a trend of gradually increasing PIP over several hours over the day -Increased PIP means there is resistance from the pt (from secretions, kinked tubing, PE, etc.)

A client will be taking amiodarone. Which baseline tests are necessary before this medication is started to monitor for side effects or toxicity? (Select all that apply) a. Complete blood count with differential b. Corneal assessments can occur c. Liver failure d. Renal function tests e. Pulmonary assessments

b. Corneal assessments can occur e. Pulmonary assessments Amiodarone is a Ca channel blocker that can cause corneal pigmentation (sometimes interfere w/ vision) & lung damage

The client with acute respiratory distress syndrome (ARDs) would exhibit which of the following symptoms? a. Increased lung compliance with increased FIO2 administration b. Decreasing PaO2 levels despite increased FIO2 administration c. Respiratory acidosis associated with hyperventilation d. Elevated alveolar surfactant levels

b. Decreasing PaO2 levels despite increased FIO2 administration

The nurse would assess a client with complaints of chest pain for which clinical manifestations associated with myocardial infarction (MI)? (Select all that apply) a. Cyanosis b. Diaphoresis c. Flushing d. Shortness of breath e. Palpitations

b. Diaphoresis d. Shortness of breath e. Palpitations May also feel: anxiety, impending doom, confusion, dizziness, dysrhythmias, chest pain, jaw pain, indigestion

The nurse is assessing with ET tube intubation and understands that correct placement of the ET tube in the trachea would be identified by which of the following? (Select all that apply) a. Fogging of the ET tube b. Positive detection of CO2 through end tidal CO2 detector device c. Equal bilateral breath sounds by auscultation d. Auscultation of air over epigastrium e. Position above the carina with chest x-ray f. ET tube is positioned 2cm above the carina verified by chest x-ray g. There is an audible air over the periumbilical area h. Auscultate lung sounds using minimal leak technique

b. Positive detection of CO2 through end tidal CO2 detector device c. Equal bilateral breath sounds by auscultation e. Position above the carina with chest x-ray f. ET tube is positioned 2cm above the carina verified by chest x-ray

Which interventions are considered best practice when suctioning an artificial airway? a. Instill 5-10 ml of normal saline in to ET tube b. Preoxygenation the client prior to suctioniong c. Hyperoxygenate the client after each pass of the suction catheter d. Limit the duration of each suction pass to 20 seconds e. Perform as needed for up to 3 total suction passes

b. Preoxygenation the client prior to suctioniong c. Hyperoxygenate the client after each pass of the suction catheter e. Perform as needed for up to 3 total suction passes Limit each suction to 10-15 seconds, NOT 20

The nurse is concerned that a client is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Bed rest with head of bed elevated b. Promoting mobility c. Antiseptic oral care d. Coughing and deep breathing

b. Promoting mobility

The nurse is preparing to administer adenosine to a client with paroxysmal supraventricular tachydysrhythmias. Which considerations should the nurse take into account when administering this medication? (Select all that apply) a. IV injection site must be far from the heart as possible b. Rapid administration over several seconds is recommended c. Constant ECG monitoring is necessary d. Administration must be followed by a normal saline bolus e. Long half-life of adenosine may prolong adverse medication effects f. Facial flushing, SOB, chest pain are common adverse effects

b. Rapid administration over several seconds is recommended c. Constant ECG monitoring is necessary d. Administration must be followed by a normal saline bolus f. Facial flushing, SOB, chest pain are common adverse effects Also have emergency equipment bedside, expect a flatline for 10-15 seconds then heart will restart, patient may feel chest pain, bradycardia, SOB, nausea, vomiting afterwards

The nurse is teaching a client about sublingual nitroglycerin (Tridil) administration. What information will the nurse include when teaching this client? a. If a tingling sensation under the tongue is felt, the tablets are no longer potent b. Take the first tablet while sitting or lying down c. Call 911 if pain does not improve after three doses d. Swallow the tablet with no more than 5mL of water

b. Take the first tablet while sitting or lying down

he nurse is reviewing the client's lab results. Which finding should alert the nurse to the (possibility) of atherosclerosis? (Select all that apply) a. Serum magnesium level of 2.7 b. Total cholesterol of 280 c. High density lipoprotein with cholesterol of 50 d. Triglycerides of 200 mg/dL e. Low density lipoproteins cholesterol 160

b. Total cholesterol of 280 d. Triglycerides of 200 mg/dL e. Low density lipoproteins cholesterol 160 Total should be below 200 Tri should be below 150 LDL should be less than 70 HDL of 50 is ok

The nursing student is performing tracheostomy care on a client on a medical surgical floor. Which action by the nurse leads to the supervising nurse to intervene? a. Using sterile rather than clean technique for the procedure. b. Applying new tracheostomy ties before removing old ones c. Cutting a slit in a woven or lined 4 X 4 gauze pad to fit around the stoma d. Using folded gauze dressings on both sides of the stoma

c. Cutting a slit in a woven or lined 4 X 4 gauze pad to fit around the stoma the gauze can fray & enter in the tube, causing aspiration

A client who has a right sided chest tube following a thoracotomy has continuous gentle bubbling in the suction-control chamber of a wet chest drain collection device. What is the most appropriate action by the nurse? a. Obtain and attach a new collection device b. Notify the surgeon of a possible pneumothorax c. Document these finding on the chart d. Document the presence of a large air leak

c. Document these finding on the chart The suction chamber should always have gentle bubbling present

A client shows occasional premature atrial contractions (PACs) on the holter monitor accompanied palpitations that resolve spontaneously without treatment. What instruction should the nurse include in the client's teaching plan? a. Take quinidine daily to prevent PACs b. Use your oxygen when you experience PACs c. Minimize or abstain from caffeine. d. Lie on your side until the episode subsides.

c. Minimize or abstain from caffeine. Caffeine, alcohol, & stress can cause atrial irritability

A client is admitted with a diagnosis of myocardial infarction. The nurse knows that the physiologic mechanism present is most likely which of the following? (NOT select all that apply) a. Partial occlusion of a coronary artery with a thrombus b. Fatty streak outside of the coronary arteries c. Myocardial tissue is abruptly and severely deprived of oxygen d. Vasospasm and uncontrolled contractility of the coronary arteries

c. Myocardial tissue is abruptly and severely deprived of oxygen

Which client does the nurse assess most carefully because of the highest risk for the development of ARDS? a. Middle-aged client receiving a blood transfusion b. Young adult with a broken leg blood transfusion c. Older adult who has aspirated his tube feeding d. Middle aged adult with COPD

c. Older adult who has aspirated his tube feeding

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed ARDS? a. Pitting pedal edema b. Chest pain c. PAWP less than 18 mm Hg d. Diffused bilateral infiltrates e. O2 of 100% but PA02 of 60

c. PAWP less than 18 mm Hg d. Diffused bilateral infiltrates e. O2 of 100% but PA02 of 60 (called refractory hypoxemia)

The nurse is assessing a client with acute respiratory distress syndrome. What is an expected assessment in this client's pulmonary edema? a. Cardiac output of 10 L/min and low systemic vascular resistance b. PAWP of 20 mm Hg and PaO2 of 55 c. PAWP of 10 mm Hg and PaO2 of 55 d. PAWP of 15 mm Hg and high systemic vascular resistance

c. PAWP of 10 mm Hg and PaO2 of 55 Pulmonary airway wedge pressure normal range: 4-12 PAWP would increase w/ cardiac issues, not regular ARDS

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolism (PE)? a. Most critically ill clients are at low risk for VTE and PE and do not require prophylaxis b. Dyspnea, chest pain, and hemoptysis occur in all clients with PE c. PE should be suspected in any client who has unexplained cardiopulmonary complaints and risk factors for VTE d. Bradycardia and hyperventilation are classic symptoms of PE

c. PE should be suspected in any client who has unexplained cardiopulmonary complaints and risk factors for VTE A PE occurs from a dislodged clot that likely started as a VTE/DVT

Which interventions are considered best practice when suctioning an artificial airway? (Select all that apply) a. Instill 5 to 10 mL of normal saline into the ET tube to facilitate secretion removal b. Limit the duration of each suction pass to 20 seconds c. Preoxygenate the client prior to the start of the procedure d. Perform as needed for up to three total suction passes e. Hyperoxygenate the client after each pass of the suction catheter

c. Preoxygenate the client prior to the start of the procedure d. Perform as needed for up to three total suction passes e. Hyperoxygenate the client after each pass of the suction catheter Limit each pass to 15 seconds MAX*

In assessing a client with respiratory failure who is intubated, the nurse understands that which is an early sign of hypoxemia? a. Bradycardia b. Clubbing of nail beds c. Restlessness d. Cyanosis

c. Restlessness Other options are later signs of hypoxemia

Suctioning​ maintains a patent airway and promotes gas exchange by removing secretions when the client is intubated. Which of the following indicates that suctioning is needed? Select all that apply. a. Decreased peak airway pressure b. Decreased heart rate c. Rhonchi d. Audible secretions e. Restlessness

c. Rhonchi (or crackles or wheezes) d. Audible secretions e. Restlessness Also: increased pulse, increased RR, visible secretions in artificial airway, increased PAP

Which assessment date collected by the nurse who is admitting a client with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI), and not stable angina? a. The pain is brought on by physical exertion b. The pain is relieved after the client takes nitroglycerin (NTG) c. The pain has lasted longer than 30 minutes d. The pain is radiating to the left arm

c. The pain has lasted longer than 30 minutes Stable angina would be relieved after 30 min S/S of a MI: Nausea, vomiting, diaphoresis, dizziness, weakness, palpitation, and SOB

During a home visit the nurse notes that a client recovering from an acute myocardial infarction has not had medication prescriptions filled at the pharmacy. What should the nurse say in response to this observation? a. "I don't blame you; I don't like to take medications every day either" b. "As long as you aren't having any symptoms, delaying the medications is acceptable" c. "Most people don't like to take medications but try to remember to get the prescriptions filled" d. "The medications will help treat the effects of your current health problem and prevent any future events"

d. "The medications will help treat the effects of your current health problem and prevent any future events"

The physician is about to perform vagal maneuvers on a client with supraventricular tachycardia. Which maneuver should the nurse expect to be performed? a. Sneezing b. Sternal friction rub c.Defibrillation d. Carotid massage

d. Carotid massage HCP will likely utilize vagal stimulation which can be done via carotid massage or valsava maneuver

The nurse is caring for a client whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). What complication does the nurse assess the client for? a. Fluid overload secondary to decreased venous return b. High cardiac index secondary to more efficient ventricular function c. Hypoxemia secondary to prolonged positive pressure at expiration d. Low cardiac output secondary to increased intrathoracic pressure

d. Low cardiac output secondary to increased intrathoracic pressure PEEP is positive pressure exerted during expiration. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis.

The nurse is caring for a mechanically ventilated client and notes the high-pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the client's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse's priority action? a. Call the rapid response team to assess the client b. Ask the respiratory therapist to get a new ventilator c. Continue to find the cause of the alarm and fix it d. Manually ventilate the client while having someone call for a respiratory therapist

d. Manually ventilate the client while having someone call for a respiratory therapist DOPE: check for Displaced tube (assess via breath sounds), Obstruction, Pneumothorax, Equipment problems Tube displacement in first 72 hours is an EMERGENCY bc the trach tract has not matured

A 38-year-old client is brought to the Emergency Department with complaints of her "heart beating out of her chest". She is diaphoretic and tachypneic and her BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva's maneuvers and three doses of adenosine have not been successful. The nurse should expect which of the following to be done next? a. Perform unilateral carotid massage b. Give epinephrine 1 mg IV and repeat in 3 minutes c. Give adenosine 6 mg IV per protocol d. Prepare the client for synchronized cardioversion

d. Prepare the client for synchronized cardioversion

The nurse provides care to a client who will be receiving electrical cardioversion. Which of the following nursing action before initiating the shock? a. Documenting the vital signs b. Telling the client what to expect c. Ensuring that the synchronize button is off d. Stating, "I am clear, are you clear? Are we all clear?"

d. Stating, "I am clear, are you clear? Are we all clear?"

A client with atrial fibrillation who takes warfarin walks into the emergency department and reports that he accidentally took too much warfarin an hour ago. The clients heart rate is 78 bpm and the BP is 120/80. A dipstick urinalysis is normal. The client does not have any obvious hematoma or petechiae and does not complain of pain. No melena, no hematemesis, no hematuria. The nurse will anticipate an order for which of the following at this time? a. Protamine sulfate b. Vitamin K c. A PTT d. aPT and INR

d. aPT and INR Check levels & HCP may order vitamin k depending on results Warfarin does not work immediately, pt would not have s/s of OD

A client with atrial fibrillation who takes warfarin walks into the emergency department and reports that he accidentally took too much warfarin an hour ago. The client's heart rate is 78 beats per minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The client does not have any obvious hematoma or petechiae and does not complain of pain. No melena, no hematemesis, no hematuria. The nurses will anticipate an initial order for which of the following at this time? a. Vitamin k b. Protamine sulfate c. aPTT d. aPTT and INR

d. aPTT and INR OD of warfarin takes more time than one of heparin - aPTT & INR would be checked, pt would likely get vitamin k (antidote)

respiratory alkalosis cause

hyperventilation

respiratory acidosis cause

hypoventilation

Normal ABG values

pH = 7.35-7.45 PaCO2 = 35-45 HCO3 = 22-26

ST Segment & T Wave

the dip after the QRS interval & the following wave which is relaxation (re-polarization), getting ready for the next beat