PN3 EXAM 2

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)

*a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag *d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with fullthickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

*a. Adherence to proper hand hygiene *b. Administering anti-ulcer medication *c. Elevating the head of the bed *d. Providing oral care per protocol e. Suctioning the client on a regular schedule ANS: A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

*a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets ANS: A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

*a. Mechanism of injury *b. Diagnostic test results c. Immunizations d. List of home medications *e. Isolation precautions ANS: A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

Which of the following interventions would be appropriate for a client who is being mechanically ventilated? (SATA)

-Secure artificial airway-Auscultate lungs every 4 hours and as needed-Monitor endotracheal tube cuff pressure once per shift-Provide alternative form of communication-Monitor arterial blood gas analysis results and adjust the ventilator as needed

Pulmonary embolism labs

ABG's PaO2 (partial pressure of oxygen in arterial blood)-FiO2(fraction of inspired oxygen) ratio falls Pulse oximetry Imaging assessment

A client is diagnosed with superior ventricular tachycardia, the nurse should prepare to administer which of the following medications?

Adenosine

The nurse is caring for a client who is experiencing an increase in cardiac contractility, which of the following will decrease cardiac contractility and reduce myocardial oxygen?

Administer beta-blockers as prescribed

Emergent or class I (red tag) (immediate threat to life or limb)

Airway obstruction shock Respiratory distress Chest pain with diaphoresis Stroke Active hemorrhage Unstable vital signs

Forensic nurse role

Are educated to obtain patients histories; collect forensic evidence; and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence also known as intimate partner violence (IPV). They recognize evidence of abuse and when to intervene on the patient's behalf. May include information about developing a safety plan or how to escape a violent relationship. Forensic nurse examiners document injuries and collect physical and photographic evidence. They may also provide testimony in court as to what was observed during the examination and information about the type of care provided.

The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first?

Ask the spouse if he wishes to be present during the resuscitation If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures.

Breathing

Assessment Administer high-flow O2 via a nonrebreather mask Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions Monitor patient response

Level II and Level III

Both typically located in community hospitals Level II Provides care to most injured patients. Transfers patient if needs exceed resource capabilities Level III Stabilizes patients with major injuries. Transfers patient if needs exceed resource capabilities

PVC

Clinical manifestations: asymptomatic vs palpitations and CP; can lead to VT, cardiomyopathy, heart failure

Multifocal

Different shapes, with the impulses generation from different sites

Pulmonary embolism cardiac assessment

Distended neck veins Syncope Cyanosis Systemic hypotension Abnormal heart sounds Abnormal ECG

Sinus Bradycardia

Everything measures normal except the HR is less than 60 Treatment may be necessary if there is symptomatic (signs of decreased cardiac output) Administer atropine to increase heart rate 60 beats/min. If medication does not work pacemaker

The nurse knows this drug will minimize the growth of existing clots and prevent the development of additional clots in the client with pulmonary embolism:

Heparin

The client sustained a blunt chest trauma and has a life threatening tension pneumothorax. Initial management of a tension pneumothorax is an immediate:

Needle thoracostomy

Quadrigeminy

PVC every 4th beat

A client is admitted to the ICU with a flail chest and placed on mechanical ventilation. The nurse should monitor for which of the following?

Pneumonia because the client is a high risk for acquiring infection

Bigeminy

Premature ventricular contraction (PVC) every other heart beat

Pulmonary Embolism Risk factors

Prolonged immobilization Central venous catheters Surgery Obesity Advanced aging Conditions that increase blood clotting History of thromboembolism

A one day post operative client is experiencing a sudden onset of chest pain, SOB, and hemoptysis. Based on history and presenting symptoms, which condition does the nurse expect?

Pulmonary Embolism (PE)

In the event of a mass casualty situation the best triage nurse is:

The RN with the most experience and best assessment skills

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?

Transfer the client to a negative-pressure room. A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative- pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

Exposure

clothing removal/temperature control

Prominent U waves

may indicate hypokalemia (low potassium)

The nurse performing a primary survey in the ED is assessing

the acuity of the patient's condition to determine priority of care the status of airway, breathing, circulation, or presence of deformity. whether the patient is responsive enough to provide needed information whether the resources of the ED are adequate to treat the patient

.A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

ANS: 660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg 6 mL/kg = 660 mL.

Vtach interventions

ASSESS - Stable: oxygen, amiodarone, procainamide, lidocaine, mag sulfate, cardioversion - Unstable: • Defibrillate • CPR • Treat the cause, meds • ACLS

Types of patients seen in E.R.

Abdominal pain Chest pain Breathing difficulties Injuries (especially falls in older adults) Headache Fever Pain (the most common symptom)

A 56 year old female presents to the emergency department complaining of lightheadedness and chest palpitations, HR is 190, BP 70/40 the cardiac monitoring shows the following. What is the appropriate treatment?

Cardioversion

Circulation

Check central pulse Assess skin color, temperature, moisture Assess mental status and capillary refill Aggressive fluid resuscitation · Insert two large-bore IV catheters · NS or LR

Stabilize/immobilize cervical spine

Collar Spinal precautions Flat bedrest Log roll

Black tag

Expectant or class IV (black tag) (expected and allowed to die) massive head injuries, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.

The nurse is caring for a client that has been in a car accident. The nurse notices the client's chest are movements are paradoxical (inward movement of the thorax with inspiration with outward movement of the thorax with expiration). The nurse knows this condition is:

Flail chest

Potential consequences of positive pressure ventilation

Increased intrathoracic pressure • PEEP increases intrathoracic pressure, which can cause a decreased blood return to the heart, decreased cardiac output, and/or hypotension • Decreased cardiac output can activate the renin-angiotensin-aldosterone system, leading to fluid retention and/or decreased urine output.

Trigeminy

PVC every third beat

R-on-T phenomenon

PVC falls on the T wave of the preceding beat; may precipitate ventricular fibrillation

The nurse is in the emergency department is using a triage system because this system ranks clients by

Severity of illness or injury

Nonurgent or class III (green tag) (walking wounded) (minor injuries that do not require immediate treatment) delayed more than 2 hours

Skin rash Strains and sprains "Colds" Simple closed fracture Contusions

Atrial Fibrillation-interventions

• Administer oxygen anticoagulant because risk of emboli meds-Adenosine (for rapid rates) Amiodarone, Diltiazem, or prepare for cardioversion.

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

a. A 22-year-old with a painful and swollen right wrist *b. A 45-year-old reporting chest pain and diaphoresis (EMERGENT) c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED

Urgent or class II (yellow tag) (major injuries that require treatment) can wait a short time for care. Treatment within 30 minutes to 2 hours.

o Patient should be treated quickly but immediate threat to life does not exist at the moment Severe abdominal pain Renal colic Open fractures with distal pulse Large wounds Displaced or multiple fractures Complex or multiple soft tissue injuries New-onset respiratory infection, especially pneumonia in older adults

Maintain airway

o Suction and/or remove foreign body o Insert nasopharyngeal/oropharyngeal airway o Endotracheal intubation o Cricothyroidotomy or tracheostomy

Ventricular tachycardia

occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action. Can lead to cardiac arrest

A-fib

•Multiple rapid impulses from many foci depolarize in the atria. 350-600 times/min. No definitive P wave can be observed only fibrillatory waves before each QRS. V fib or VF: electrical chaos in the ventricles; the ventricles quiver and there is no CO...IT IS FATAL in 3-5 minutes

You are the nurse caring for a client who has developed a tension pneumothorax. The physician performs an emergency ECHO at the bedside and determines that your clients cardiac output is 3L/min. As the nurse caring for this client you understand that a cardiac output of 3L/min is:

→ 3L/min is below normal and puts the client at increased risk of poor perfusion and death. (normal 4-8 range)

A nurse is interpreting the ECG of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

→ Atrial depolarization

VAP interventions

· Elevate head of bed at least 30 degrees · Suctioning preventing aspiration · Oral care · Hand hygiene · Pulmonary hygiene, including chest physiotherapy, postural drainage · Turning the patient and positioning.

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

A 26-year-old male who has pale, cool, clammy skin (s/s of shock) The client with pale, cool, clammy skin is in shock and needs immediate medical attention

Primary Survey in E.R

(A) Airway/cervical spine Establish a patent airway by positioning, suctioning, and oxygen as needed. Protect the cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma Scale (GCS) score is 8 or less or the patient is at risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation. (B) Breathing Assess breath sounds and respiratory effort. Observe for chest wall trauma or other physical abnormality. Prepare for chest decompression if needed. Prepare to assist ventilations if needed. (C) Circulation Monitor vital signs, especially blood pressure and pulse. Maintain vascular access with a large-bore catheter. Use direct pressure for external bleeding; anticipate need for a tourniquet for severe, uncontrollable extremity hemorrhage and use of a hemostatic dressing. (D) Disability Evaluate the patient's level of consciousness (LOC) using the GCS. Re-evaluate the patient's LOC frequently. (E) Exposure Remove all clothing for a complete physical assessment. Prevent hypothermia (e.g., cover the patient with blankets, use heating devices, infuse warm solutions).

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

*a. Acknowledge the frightening nature of the illness. *b. Delegate a back rub to the unlicensed assistive personnel (UAP). *c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. *e. Stay with the client and speak in a quiet, calm voice. ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

*a. Allow visitors at the clients bedside. *b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. *d. Provide back and hand massages when turning. *e. Turn the client every 2 hours or more. ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

*a. Alteplase (Activase) (THROMBOLYTIC) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin) ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?

*a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR). ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

*a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths. ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?

*a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response. ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

*a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately. ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)

*a. Chest wall stiffness *b. Decreased muscle strength c. Inability to cooperate *d. Less lung elasticity e. Poor vision and hearing ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?

*a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client. ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)

*a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure *d. Increase in blood pressure *e. Decrease in urine output f. Increase in urine output ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall

A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns?

*a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. b. The government has a program for quick licensure activation wherever you are deployed. c. During a time of crisis, licensure issues would not be the governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working. ANS: A When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?

*a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

*a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching?

*a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs. ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.)

*a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses *c. Neck injury and numbness of both legs *d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse *f. Bruising and pain in the right lower abdomen ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

*a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family. ANS: A The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?

*a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility. ANS: A To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)

*a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis (CORRECT) b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources (TRIAGE NURSE) c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs (EMT) d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow- up care for victims of rape, child abuse, and domestic violence (FORENSIC NURSE) *e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration (CORRECT) ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow- up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs enroute to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.)

*a. Smoking cessation *b. Stress reduction and management c. Avoiding vagal stimulation *d. Adverse effects of medications e. Foods high in potassium ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests?

*a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.)

*a. Until your incision is healed, do not submerge your pacemaker. Only take showers. *b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). *e. Do not lift your left arm above the level of your shoulder for 8 weeks. ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?

*a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone. ANS: A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

When are PVCs a Problem?

- Increase from the patient's normal amount - Multiple PVCs in a row - PVC falls on the T wave of previous beat - Multifocal (they arise from different cells, therefore they are different shapes) A wide bizarre QRS

SVT medications

- adenosine, esmolol, diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly used as an agent to terminate a sustained episode of supraventricular tachycardia.

SVT Interventions

- eliminate the cause - radiofrequency catheter ablation - vagal stimulation - cardioversion

A client with pulmonary embolism will have which of the following interventions? (SATA)

-IVC (inferior vena cava filter)-Embolectomy-Heparin drug therapy

Emergent interventions for a client with burns to the face and trunk/arms may include which of the following? (SATA)

-Inserting an indwelling urinary catheter-Intubating the client-Starting an intravenous solution of Ringer's lactate

Which of the following interventions are for a client diagnosed with pneumothorax? (SATA)

-Monitor respiratory and circulatory function-Assess for tracheal deviation-Provide analgesics-Insertion of a chest tube

A client has just been intubated following cardiac arrest. The nurse knows that in order to ensure the endotracheal tube (ET) has been placed properly is to: (SATA)

-Observe for symmetrical chest movement -Assess breath sounds bilaterally -Verify with chest x-ray

Post-operative complications after pacemaker insertion will include which of the following? (SATA)

-Pericardial effusion-Infection-Hematoma at insertion site-arrhythmias

A client with decreased cardiac output will exhibit which of the following signs and symptoms? (SATA)

-Tachycardia -Elevated respirations -Dizziness (syncope) -Pallor

A client complains of fluttering in his chest, the nurse applies the cardiac monitor and correctly identifies the following rhythm as:

Atrial fibrillation

A client with a history of dysrhythmias is placed on a cardiac monitor. The following rhythm is observed. The nurse correctly documents is as which rhythm?

Atrial flutter

Pulmonary embolism respiratory assessment

Dyspnea Tachycardia Tachypnea Pleuritic chest pain Dry cough *Hemoptysis *chest pain *SOB

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care?

Forensic nurse examiner The forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

PVC can cause

Hypokalemia, meds, hypoxemia, MI, infection, hypovolemia, stimulants

Analysis: Interpreting Pulmonary Embolism

Hypoxemia Hypotension Potential for excessive bleeding Anxiety *Hypoxemia can trigger anxiety and sense of impending doom.

Premature Ventricular Contraction or PVC

If it arises from the Ventricular area, it will be a QRS which is wide and bizarre shaped Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization

The client has been intubated due to Acute Respiratory Distress Syndrome. Following a chest x-ray for ET tube placement, the tube was readjusted. The client's abdomen is distended. In order to decompress the abdomen the intervention necessary will be:

Insert a nasogastric tube (NG)

The nurse is preparing for which intervention when she gets the code (crash) cart, airway equipment box, calls for the appropriate personnel and sets up suction?

Intubation

Disability

LOC AVPU o A=alert o V=responsive to voice o P=responsive to pain o U=unresponsive GCS Pupils

Community relations or public information officer

Person who serves as a liaison between the health care facility and the media to release only appropriate and accurate information. Important role to delineate in advance. Mass casualty incidents tend to attract a large amount of media attention. This staff member can draw media away from the clinical areas so essential hospital operations are not hindered.

Hospital incident commander

Physician or administrator who assumes overall leadership for implementing the emergency plan. This role can also be fulfilled by a nursing supervisor functioning as the on-site hospital administrator after usual business hours. The hospital incident commander's role is to take a global view of the entire situation and facilitate patient movement through the system, while bringing in personnel and supply resources to meet patient needs. a hospital incident commander might dictate that all patients due to be discharged from an inpatient unit be moved to a lounge area immediately to free up hospital beds for mass casualty victims. He or she could also direct departments such as physical therapy or a surgical clinic to cancel their usual operations to convert the space into a minor treatment area. The incident commander assists in the organization of hospital-wide services to rapidly expand hospital capacity, recruit paid or volunteer staff, and ensure the availability of medical supplies.

Triage officer

Physician or nurse who rapidly evaluates each patient to determine priorities for treatment. When physician resources are limited, an experienced nurse may assume this role. The triage officer rapidly evaluates each person who presents to the hospital, even those who come in with triage tags in place. Patient acuity is re-evaluated for appropriate disposition to the area within the ED or hospital best suited to meet the patient's needs.

Medical command physician

Physician who decides the number, acuity, and resource needs of patients/ victims arriving from the incident scene to the hospital and organizing the emergency health care team response to the injured or ill patients. Responsibilities include identifying the need for and calling in specialty-trained providers such as: • Surgeons (trauma, neuro, orthopedic, plastic, and/or burn) • Pulmonologists • Infectious disease physicians • Industrial hygienists • Radiation safety personnel In smaller hospitals with limited specialty resources, the medical command physician might also help determine which patients should be transported out of the facility to a higher level of care or to a specialty hospital (e.g., burn center).

PR interval measurements and define what is happening in the body

The PR interval represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers. It's measured from the beginning of the P wave to the PR segment, measures from 0.12 to 0.20 seconds.

QRS interval measurements and define what is happening in the body

The QRS complex represents ventricular depolarization. Depending on the lead selected will depend on the shape. The Q wave is the first negative deflection. Q-wave is not present in all leads. When you can see it, it's small and represents the initial ventricular septal depolarization. Abnormal Q wave represents myocardial necrosis. R wave is the first positive deflection. The R wave can be small, large, or absent, depending on the lead. The S wave is the negative deflection following the R wave and is not present in all the lead.

Couplet or pair

Two sequential PVCs

Unifocal

Uniform upward or downward deflection, arising from the same ectopic focus

Level 1

Usually located in large teaching hospital systems in densely populated areas Provides a full continuum of trauma services for adult and/or pediatric patients Conducting research is a requirement for trauma center verification

Level IV

Usually located in rural and remote areas. Provides basic trauma patient stabilization and advanced life support within resource capabilities. Arranges transfer to higher trauma center levels as necessary

A client is unresponsive and has no pulse, the nurse notes the electrocardiogram tracing shows continuous larger and bizarre QRS complexes measured greater than 0.12, this rhythm is identified as:

Ventricular tachycardia (DEFIBRILLATE)

A nurse is triaging clients in the emergency department. Which client should be considered urgent?

a. A 20-year-old female with a chest stab wound and tachycardia (EMERGENT) b. A 45-year-old homeless man with a skin rash and sore throat (NON-URGENT) *c. A 75-year-old female with a cough and a temperature of 102 F (URGENT) d. A 50-year-old male with new-onset confusion and slurred speech (EMERGENT) ANS: C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent?

a. A 44-year-old with chest pain and diaphoresis (EMERGENT) b. A 50-year-old with chest trauma and absent breath sounds EMERGENT) *c. A 62-year-old with a simple fracture of the left arm NON-URGENT) d. A 79-year-old with a temperature of 104 F (URGENT) ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?

a. A 45-year-old who takes an aspirin daily *b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?

a. Administer intravenous adenosine. *b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side. ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?

a. Administer intravenous diltiazem (Cardizem). *b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature. ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. *d. Prepare to assist with intubation. ANS: D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?

a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. *c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client. ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

a. Apply oxygen at 100%. b. Assess the respiratory rate. *c. Ensure a patent airway. d. Start two large-bore IV lines. ANS: C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time?

a. Are you sure no more victims are coming into the ED? *b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control? ANS: B Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?

a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. *d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

a. Assess the client for sedation needs. b. Get family permission for restraints. *c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools. ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

a. Assess the clients lung sounds. *b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs. ANS: B This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

a. Assessing that the ventilator settings are correct *b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

a. Assessing the clients platelet count *b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. *c. Exercise on a regular basis. *d. Maintain a healthy weight. *e. Stop smoking cigarettes. ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?

a. Determine if the tube is kinked. b. Ensure all connections are patent. *c. Listen to the clients lung sounds. d. Suction the endotracheal tube. ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first?

a. Begin external temporary pacing. b. Assess peripheral pulse strength. *c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine. ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. *c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation. ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2 , the nurse cannot make that judgment.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information: Shortness of breath for 20 minutes Feels frightened Cant catch my breath LABS: pH: 7.12 PaCO2 : 28 mm Hg PaO2 : 58 mm Hg SaO2 : 88% Physical Assessment: Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?

a. Call respiratory therapy for a breathing treatment. *b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants. ANS: B This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the clients presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

a. Client who had a reaction to contrast dye yesterday *b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma *d. Older client who is 1-day post hip replacement surgery *e. Young obese client with a fractured femur ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?

a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. *c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders. ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?

a. Contact the on-call orthopedic surgeon. *b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic. ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

a. Decrease the heparin rate. *b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin). ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?

a. Decreased intraocular pressure b. Increased heart rate *c. Short period of asystole d. Hypertensive crisis ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?

a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness *d. Multiple fractured ribs and shortness of breath (EMERGENT RED TAG) ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?

a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. *d. You seem upset. I have time to talk if you'd like. ANS: D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. *c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found. ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

a. Ensure the client has adequate sedation. b. Find another provider to intubate. *c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation. ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.)

a. Foley catheterization *b. Needle decompression *c. Initiating IV fluids d. Splinting open fractures *e. Endotracheal intubation *f. Removing wet clothing g. Laceration repair ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

a. Hamburger and French fries *b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips ANS: B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

a. Hemoglobin: 14.2 g/dL *b. Platelet count: 82,000/L (THROMBOCYTOPENIA) c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3 ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?

a. I should wear a snug-fitting shirt over the ICD. *b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication. ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?

a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. *d. Communicate the clients death to the family in a simple and concrete manner. ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

a. Instruct the client to eliminate all vitamin K from the diet. *b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush. ANS: B Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?

a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. *d. It is hypoxemia that persists even with 100% oxygen administration. ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?

a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. *d. It will prevent ulcers from the stress of mechanical ventilation. ANS: D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)

a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. *b. Use two identifiers before each intervention and before mediation administration. *c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. *d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections. ANS: B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

a. Level I Located within remote areas and provides advanced life support within resource capabilities (LEVEL 3) *b. Level II Located within community hospitals and provides care to most injured clients (CORRECT) c. Level III Located in rural communities and provides only basic care to clients (LEVEL 4) d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients (LEVEL 1) ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?

a. Make certain that your bath water is warm. *b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running. ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?

a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. *d. Ensure that everyone is clear of contact with the client and the bed. ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?

a. Sinus tachycardia *b. Speech alterations c. Fatigue d. Dyspnea with activity ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.)

a. Older adult in the medical decision unit for evaluation of chest pain *b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin *e. Client on the medical unit for wound care ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take?

a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. *c. Arrange for critical incident stress debriefing. d. Talk individually with staff members. ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)

a. Paramedic Decides the number, acuity, and resource needs of clients *b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital *d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next?

a. Perform a pericardial thump. *b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status. ANS: B The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond?

a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. *c. You sound anxious about being a single parent. d. At least your children still have you in their lives. ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the clients distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the clients feelings and situation.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

a. Poor visual acuity *b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery ANS: B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.)

a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. *d. Screen for depression and suicide. *e. Complete a functional assessment. ANS: D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?

a. Pulmonary auscultation b. Pulse strength and amplitude *c. Level of consciousness d. Mobility and gait stability ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition?

a. Sotalol (Betapace) *b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine) ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust?

a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. *c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings. ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the clients belongings and personal space

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs NursingAssessment............................................................................. Based on the assessments, which action should the nurse take?

a. Stop the infusion and flush the IV. *b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe. ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond?

a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. *c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse. ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the clients question.

A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?

a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. *d. Ventricular and atrial depolarizations are initiated from different sites. ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. *d. The upper peak airway pressure limit alarm is on. ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond?

a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. *c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care. ANS: C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip?

a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) *d. Sinus rhythm with premature ventricular contractions (PVCs) ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

Penetrating trauma

caused by injury from sharp objects and projectiles. Examples are wounds from knives, ice picks, other comparable implements, and bullets (gunshot wounds [GSWs]) or pellets. Fragments of metal, glass, or other materials that become airborne in an explosion (shrapnel) can also produce penetrating trauma. Each mechanism has the risk for specific injury patterns and severity that the trauma team considers when planning diagnostic evaluation and management strategies. Certain injury mechanisms such as a gunshot wound to the chest or abdomen or a stab wound to the neck are so highly associated with life-threatening consequences that they automatically require trauma team intervention for a rapid and coordinated resuscitation response.

Pulmonary Embolism Planning and Implementation: Responding

· Oxygen therapy (nasal cannula, mask) · Continuous patient monitoring · Obtain adequate venous access · Continuous monitoring pulse ox · Drug therapy (Anticoagulants, Fibrinolytics) · Assess for bleeding every 2 hours · Examine all stool, urine, drainage, vomitus for gross blood; test for occult blood · Measure abdominal girth every 8 hours · Monitor lab values · Surgical management (embolectomy, inferior vena cava filtration) · INTERVENTIONS-IVC (inferior vena cava filter) -Embolectomy -Heparin drug therapy

Presence of U wave means??

• Hypokalemia electrolyte imbalance • Represent repolarization of the Purkinje fibers

Premature Ventricular Complexes

• Increased irritability ventricle; early complexes followed by a pause • Interventions: eliminate the cause, ***Amiodarone, Lidocaine, electrolyte replacement

Pneumothorax recognition

• New onset of decreased breath sounds • Unequal chest excursion • Reduced (or absent) breath sounds of the affected side on auscultation • Hyperresonance on percussion • Prominence of the involved side of the chest, which moves poorly with respirations • When severe, deviation of the trachea away from the midline and side of injury toward the unaffected side (indicating pushing of tissues to the unaffected side [a mediastinal shift] from increasing pressure within the injured side) • For tension pneumothorax, additional assessment findings also may include: • Extreme respiratory distress and cyanosis • Distended neck veins • Hemodynamic instability • **Tracheal deviation to unaffected side • The client sustained a blunt chest trauma and has a life-threatening tension pneumothorax. Initial management of a tension pneumothorax is an immediate: **Needle thoracostomy

SVT

• Rapid stimulation of atrial tissue; rate >100 • Absent P wave (Cannot distinguish a P wave after the HR gets fast) • Paroxysmal SVT: starts and ends suddenly with or without treatment. • Clinical Manifestations: depend on duration and rate

Vfib

• Squiggly line • Code BLUE • V fib or VF: electrical chaos in the ventricles; the ventricles quiver and there is no CO...IT IS FATAL in 3-5 minutes

Atropine- anticholinergics

• Used for bradycardia • Monitor HR and rhythm after administration; increased rate is expected

Adenosine- antiarrhythmic

• Used for paroxysmal SVT • Have emergency equipment available because a short period of asystole is common after administration; bradycardia and hypotension may occur • Facial flushing, shortness of breath, and chest pain are a common side effect's • A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? Clients usually respond to adenosine with a short period of asystole.

Vtach- Ventricular Tachycardia (VT)

• characterized by the absence of P waves, wide QRS complexes(longer than 0.12 seconds) and typically rate between 140-180 impulse/minutes. The rhythm is regular. 4 or more ventricular beats in a row • Rate > 150 bpm up to 250bpm can be fatal decreased perfusion to the brain

Ventricular Fibrillation interventions

• defibrillate, • ACLS • Oxygen • Meds • CPR • treat the cause

Epinephrine- alpha- and beta-adrenergic agonists

• jump starts the heart • rescue med

Ventricular Fibrillation/Atrial fibrillation manifestations

• loss of consciousness • Pulse-less • Apneic • leads to death

Amiodorone- antiarrhythmic

• treat rapid rates. Treats V-tach, A-flutter, A-fib • continually monitor ECG rhythm during infusion; bradycardia and AV block can occur • This drug can cause serious toxicities (lung damage, visual impairment). As a result, approval is limited to use for life-threatening dysrhythmias. However, because of efficacy, use remains very common • Corneal pigmentation occurs in most patients, but it generally does not interfere with vision.