CC Final Exam Study Cards

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration?

20-25 mm Hg

Vtach

3+ PVCs in a row HR > 100 bpm (100-200bpm) Regular P-wave absent, QRS wide & bizarre

A nurse is caring for a client newly diagnosed with mitral valve prolapse. The health care provider indicates the client has probably had this condition for years. What factor is important for the nurse to consider when teaching the client about valvular disease?

"The client with mitral valve prolapse probably had no health symptoms."

The nurse completes an assessment of a client with mitral regurgitation. What statement represents the appropriate physical finding for a client with this condition?

"The high-pitched blowing sound at the apex is indicative of a systolic murmur."

aortic stenosis murmur

"mid-systolic ejection murmur best heard at the 2nd right intercostal space" think: S-S (stenosis-systolic)

diastolic heart failure

(filling problem) -- the inability of the left ventricle to relax normally, resulting in fluid backing up into the lungs "dia-fill"

Vfib treatment

*defibrillation* and CPR -treat 5Hs and Ts -call code and help as appropriate -epi and amiodarone -ICD after

Indication for defibrillation

*pulseless* ventricular tachycardia and ventricular fibrillation

What is the benefit of a tracheostomy?

- bypasses an upper airway obstruction - allow removal of secretions, - permits use of long term ventilation - prevent aspiration of secretions in unconscious/paralyzed patient - replaces ET tube

Vessels used for CABG

-Greater sapheneous vein -Lesser sapheneous vein -Right and left internal mammary arteries

A 1-minute electrocardiogram (ECG) tracing of a client with a regular heart rate reveals 25 small, square boxes within an RR interval. The nurse correctly identifies the client heart rate as

60 an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.

A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn.

7:30 p.m. to 9:30 p.m.; 24 to 36 hours The greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours.

What is the client's central venous pressure reading goal?

8-12mmHg

Which systolic BP supports diagnosis of septic shock?

< or = 100 mmHg

Oliguria is define as urine output less than

0.5 mL/kg/hr

CABG complications

1. Bleeding (hemorrhage!) - patient has been cooled during surgery; if they are overweight, heparin may be stored in fat cells as a result of hypothermia. *As the patient is rewarmed, heparin can be released from cells and increases the risk of bleeding* 2. Anemia 3. Fluid & electrolyte imbalances - bleeding, anemia, and fluid & electrolyte imbalances are all general complications associated with bypass and requires close monitoring of renal function 4. Hypothermia - need to rewarm; *hypothermia places patient at risk for v. fib* 5. Infection

What are appropriate interventions for a patient who is intubated and is on a mechanical ventilator with continuous sedation in order to prevent ventilator associated pneumonia (VAP)?

1. Elevate HOB 35-45 degrees 2. Daily sedation vacation & weaning protocols 3. Oral care w/ chlorohexidine 4. Hand hygiene

Pacemaker Universal Code

1. Paced (A, V, D) 2. Sensed (A, V, D, O) 3. Response (I, T, D, O)

A client with diabetes is in the ER due to vomiting, diarrhea, weight loss of 8lbs over 2 days. Vital signs taken at triage indicate client is in hypovolemic shock. What are your steps in the correct order of priority.

1. Place client in modified Trendelenburg position 2. Initiate IV site & prescribed IV fluids 3. Assess capillary blood glucose level 4. Collect a stool specimen for culture

What are some indicators that a patient may be developing VAP?

1. Positive sputum culture 2. Fever (over 100.3/38) 3. Chest x-ray shows new infiltrates

A client is admitted to the ER after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60, HR of 145. Skin is cool & clammy. Which medical order for this client will the nurse complete first?

100% Oxygen via nonrebreather mask Rationale: management in all types and all phases of shock includes the following: support of respiratory system with supplemental oxygen/mechanical vent, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone

A client presents to the emergency department reporting chest pain. Which order should the nurse complete first?

12-lead ECG

A client experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers what?

A continuous infusion of TPN

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock?

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

In the prerenal phase of AKI, you expect to assess

A drop on BP or an interruption of blood flow to the kidneys

Cardiogenic shock is seen most frequently as a result of

A myocardial infarction

The RN determines that a patient in shock is experiencing a decreased stroke volume when what occurs?

A narrowed pulse pressure

What is an earlier indicator of shock than a drop in systolic BP?

A narrowing/decreased pulse pressure

What is spinal shock?

A sudden depression of reflex activity (areflexia) below the level of spinal injury

What is the purpose of analgesics and sedatives for a patient on a mechanical ventilator?

Analgesics (IV morphine) & sedatives (propofol) to manage pain, reduce anxiety, and limit risk of accidental self-extubation or tube dislodgment

One cause of prerenal acute kidney injury that is a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability is

Anaphylaxis

The nurse would assess a patient with CKI and decreased erythropoietin for

Anemia

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?

Apply airtight dressing.

Cardiogenic shock is characterized by

Arrhythmia, valve malfunction, cardiomyopathy, pericarditis, PE and basically a reduced cardiac output

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

A nurse is caring for a patient with a chest tube, they notice that there is continuous* bubbling in the water seal chamber. What does the nurse know to do next?

Assess for an air leak in the system,

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels.

The nurse is reviewing lab results of a client with a chest tube. They notice that the WBC came back elevated. The nurse should:

Assess the client for other signs of infection & report to provider

The RN knows that the vascular access for PD should be

Assessed for patency Assessed for signs of potential infection NOT be used for blood pressure or blood draws

Priority for Shock treatment involves

Assessing those at greatest risk for shock and implementing early and aggressive interventions to reverse tissue hypoxia

Nursing management involved in the care of a patient with ARF

Assist with ET intubation & maintenance of mechanical ventilation Assessment of respiratory status (level of responsiveness (LOC), ABGs, SpO2, & VS Interventions: turning schedules, mouth care, skin care, ROM of extremities to prevent complications (atelectasis)

Which of the following would the nurse expect to assess in a conscious client with hepatic encephalopathy?

Asterixis Hepatic encephalopathy is manifested by numerous central nervous system effects including disorientation, confusion, mood swings, reversed day-night sleep patterns with sleep occurring during the day, agitation, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy. As hepatic encephalopathy becomes more severe, the client becomes stuporous and eventually comatose.

A patient exhibited signs of altered ventilation-perfusion ratio. The nurse is aware that when ventilation is impaired but perfusion is adequate this could indicate

Atelectasis

A client with a chest tube develops cyanosis, dyspnea and reports chest pain/discomfort. The nurse knows that this could indicated what complication associated with chest tubes?

Atelectasis (alert HCP immeidately)

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia

The purpose of kidney transplant is to

Avoid dialysis and improve QOL

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? Being an athlete Male gender Young age Alcohol/drug use

Being an athlete The predominant risk factors for SCI include young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use.

Most common side effect of recombinant human activated protein C (rhAPC)?

Bleeding

Shock occurs when tissue perfusion is inadequate to deliver oxygen to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is

Blood pressure

What is the consequence of the release of catecholamines in the skeletal muscles during the compensation stage of shock?

Blood supply to the skeletal muscles increases.

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

Which clients would be at an increased risk for anaphylactic shock?

Client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55 year old with Spina Bifida (SB at risk for a latex allergy) Client who reports allergy to peanuts that causes throat swelling

A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients?

Clients with recurrent life-threatening tachydysrhythmias

Client who is receiving at-home peritoneal dialysis therapy. Which finding indicated the client is developing peritonitis?

Cloudy dialysate effluent

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:

Cold, clammy skin & tachycardia

The RN obtains BP of 120/78 from a patient in hypovolemic shock. Since the BP is within normal limits, what stage of shock does the nurse realize the client is experiencing?

Compensatory Phase (In the compensatory phase, the BP remains within normal limits)

How does a nurse prevent a Pulmonary Embolism?

Compression sequential stockings, anticoagulants (heparin—short half life/rapid tx—monitor for complications draw pTTs q6hrs)

The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?

During ventricular depolarization

The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client?

Dyspnea, fatigue, and weakness

Nutritional information for a patient on hemodialysis includes

Eat foods such as milk, fish, eggs Restrict sodium to 2k - 3K mg daily Restrict fluid to daily urinary output plus 500-800mL Potassium, sodium & phosphorous should be restricted

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid

What diagnostic* test is done to rule out cardiac origin in patient with ARDS?

Echocardiogram

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

Which statement about lung compliance is correct?

Elastic recoil relates inversely to compliance

In the Progressive stage of shock the nurse understands that what is expected

Electrolyte imbalance Metabolic Acidosis Respiratory Acidosis Peripheral Edema Irregular tachyarrythmias HypOtension Pallor Cool & clammy skin Altered LOC

The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?

Elevate the head of the bed.

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching? Engage in exercise daily. Restrict dietary potassium. Avoid any alcohol. Drink 3 liters of fluid per day.

Engage in exercise daily.

Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure?

Fluid volume excess because the oliguric phase is marked by fluid retention

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

GI hemorrhage

What is complication associated with long-term mechanical ventilation? Prevention?

GI stress ulcers (bleeding) Prevention: prophylactic administration of H2 blockers & PPI's

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except:

Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?

Glomerulonephritis

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

Grade 3 concussion Grade 1: no loss of consciousness, mental affects last < 15 min Grade 2: no loss of consciousness, mental affects last > 15 min Grade 3: ANY loss of consciousness for any duration of time

The nurse is caring for a client with cardiac compromise related to mitral valve impairment. Which outcome of the eroding of the mitral valve is most significant?

HF

If the client is hemodynamically stable. Which dialysis method would be most appropriate?

Hemodialysis

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?

Hemodilution

What are the internal (fluid shift) risk factors (causes) for hypovolemic shock?

Hemorrhage Burns Ascites Peritonitis Dehydration

A client receiving PD, the RN notices leakage.. what should the RN do next?

Hold exchanges, rest, use small volume exchanges

What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)?

Hydrating with saline IV before the test

A client with chronic kidney disease becomes confused and reports abdominal cramping, increased HR, and numbness of the extremities. The RN relates these symptoms to which lab value?

Hyperkalemia

As renal failure progresses, the nurse identifies the following indicators associated with the disease:

Hyperkalemia due to decreased potassium excretion Anemia Hypocalcemia Metabolic acidosis from decreased acid secretion by the kidneys Hypoalbuminemia due to excess protein loss due to damaged glomerular membrane

Which physiologic responses are the same regardless of the type of shock?

Hypoperfusion of tissues, hyper metabolism, and activation of inflammatory response

During the dialysis the nurse should monitor for what complications

Hypotension Muscle cramping due to F&E rapidly leaving the extra cellular space Dysrhythmias resulting from electrolyte & pH changes or removal of anti arrhythmic meds Air embolism

What would lead to prerenal failure?

Hypotension, sepsis, dehydration

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

Hypovolemia

What are some causes of Acute Kidney Injury?

Hypovolemia Hypotension Reduced CO & HF Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload?

IV morphine

The nurse understands that early interventions along the continuum of shock involves

Identifying the cause of shock Administering IV fluids & oxygen & obtaining labs to rule out & treat metabolic imbalances or infections

A client seeks medical attention for a new onset of fatigue and changes in coordination. Which additional assessment finding indicates to the nurse that the client is demonstrating signs of low oxygenation? Select all that apply.

Impaired thought process Agitation Shortness of breath

Acute dialysis is indicated during which situation?

Impending pulmonary edema Increasing levels of serum potassium Fluid overload Increasing acidosis

mitral valve prolapse

Improper closure of the valve between the heart's upper and lower left chambers.

Major colonial use of dobutamine

Increase cardiac output

A client with CRF is ready for discharge. The nurse should reinforce which dietary instruction?

Increase your carbohydrate intake

In the compensatory stage of shock, does the heart rate increase or decrease?

Increase. (I.e., Tachycardia)

What is a characteristic of the intrarenal category of ARF?

Increased BUN

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?

Increased pulmonary artery diastolic pressure

A patient seen in the clinic has been diagnosed with stage A heart failure (according to the staging classification of the American College of Cardiology [ACC]). What education will the nurse provide to this patient?

Information about ACE inhibitors and risk factor reduction Teaching for patients with stage A heart failure should include information about risk factor control and use of ACE inhibitors. Beta blockers pertain to stages B-D, and diuretics implantable cardioverters/defibrillators to stages C-D.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

Insertion of a nasogastric tube Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration.

A patient has a persistent third-degree heart block and has had several periods of syncope. What priority treatment should the nurse anticipate for this patient?

Insertion of a pacemaker

Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion?

Instruct the client to restrict food and oral intake

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

The nurse is taking care of a client with a chest tube who sudden develops pallor and is tachycardic. What does the nurse expect may be the cause?

Internal hemorrhaging--alert provider asap

Which stage of shock encompasses mechanical ventilation, altered LOC, and profound acidosis?

Irreversible

Patient is not responding to treatments to maintain MAP > 65 or systolic BP above 90 mmHg. In this stage, (what stage is this?) the nurse should do what?

Irreversible/Refactory Stage Encourage the family to touch & talk to the patient

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Irrigates the wound to remove debris Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Shaves the hair around the wound

Irrigates the wound to remove debris

If chest tube/drainage system become disconnected, the nurse knows that this could lead to what complication? And what should the nurse do?

It could lead to a pneumothorax and the nurse can put the end of the tube in a bottle of sterile water to act as a temporary water seal

In the Prerenal stage of AKI, what is the cause?

It is caused by conditions or substances that interfere with blood flow to the kidneys Ex. Hypovolemia, Hypotension, drop in cardiac output

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement?

Keep the patient's affected leg straight.

What is the treatment of choice for ESRD?

Kidney transplant

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn.

The client develops hypotension, declining mental status, and severely decreased urinary output. Which IV fluid will you expect to be prescribed for the client?

Lactated Ringers Solution (Lactate ions convert to bicarbonate that help buffer acidosis experienced during shock)

In the initial stage of shock the nurse would expect what level to be elevated?

Lactic acid

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock (fainted) following insertion of an IV catheter. The nurse first...

Lays the client flat with feet elevated Rationale: to minimize pooling of blood in legs and restore blood flow to the brain, the nurse lays the client flat and elevated legs

An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region?

Leads V3 & V4

A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?

Left sided heart failure

Incomplete closure of the mitral valve results in backflow of blood from the: (MVR)

Left ventricle to left atrium MVR = LV-LA

The nurse caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?

Less than 400 mL

For a client in the oliguric phase of ARF, which nursing intervention is the most important?

Limiting fluid intake

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?

Liquid blood component is lost into extravascular space

Which is the hallmark of heart failure?

Low ejection fraction (EF)

A nurse is evaluating a client's drop in MAP to 50 mmHg during progressive shock. What client assessment would follow with the drop in pressure?

Low urine output Rationale: low MAP will lead to decreased kidney function & low urine output—clients will have tachycardia, slow respirations, bloody diarrhea)

On auscultation, the nurse suspects a diagnosis of mitral valve stenosis when which of the following is heard?

Low-pitched, rumbling diastolic murmur at the apex of the heart

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund & Brower Method

Classic sequence of developing MODS

Lung dysfunction Fluid balance Hyper metabolism Liver dysfunction Kidney dysfunction Bleeding disorder Cardiovascular instability Neurologic deterioration

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is

MVC

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Select all that apply.

Manual resuscitation (AMBU) bag Pulse oximetry

The left atrium is enlarged in what valvular disease?

Mitral stenosis

A patient at the clinic describes shortness of breath, periods of feeling "lightheaded," and feeling fatigued despite a full night's sleep. The nurse obtains vital signs and auscultates a systolic click. What does the nurse suspect from the assessment findings?

Mitral valve prolapse

The nurse expects to see which of the following characteristics on an ECG strip for a patient who has third-degree AV block?

More P waves than QRS complexes

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

Morphine sulfate (Morphine)

Vfib

Most common dysrhythmia in patients in sudden cardiac arrest Rapid, disorganized/chaotic ventricular rhythm → quivering of ventricles HR > 300 bpm

In Pressure Support Ventilation the patient must be able to do what?

Must be able to draw in a breath on their own

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)? Ineffective right ventricular contraction Myocardial ischemia Pulmonary embolus Cystic fibrosis

Myocardial Ischemia

Which is one of the first signs of organ failure?

Myocardial depression

Assessing a patient for shock, knowing the primary cause of cardiogenic shock is

Myocardial infarction

Discharge teaching for a patient with MVP

NO prophylactic abx for dental work!!

Which condition may cause in the intrinsic (intrarenal) form of ARF?

Nephrotoxic injury secondary to use of contrast media

A nurse caring for a client after epidural anesthesia observed that the client is beginning to present with dry skin, bradycardia, and hypotension. What type of shock is the nurse assessing?

Neurogenic

Patient with a spinal cord injury is at risk for what kind of shock?

Neurogenic shock

Which vasodilator medication is used in the treatment of shock?

Nitroglycerin

The nurse understands that suctioning a patient places the patient at risk for trauma. In order to prevent this, the nurse suctions:

ONLY when necessary Suctions OUT, never in (never apply suction when inserting catheter into airway) ONLY for 10 seconds or less Administers 100% O2 3 seconds before suctioning AVOIDs suctioning before ABG draw AVOIDs suctioning routinely (risk for ALI-suction only when needed)

A patient has been diagnosed with postrenal failure. Which is a possible cause?

Obstruction—renal calculi

Client admitted to the hospital following a Myocardial Infarction. Two days later the client exhibits a BP of 90/58, HR 132, RR 32, temp of 101.8 & am in warm & flushed. What are the appropriate interventions you should take?

Obtain a urine culture (identify source of infection) Administer pantoprazole IV daily (to prevent stress ulcers) Monitor urine output every hour

Which of the following occurs during the second phase of acute renal failure?

Oliguria

Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys?

Oliguria

Etiology of Shock (What 3 events?)

One of three events: 1. Blood volume decreases 2. Heart fails as effective pump 3. Peripheral blood vessels massively dilate

When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias?

PVC

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2

Type 2 HYPERCAPNIC Respiratory Failure

PaO2 < 60 mm Hg, PaCO2 > 50 mm Hg, pH < 7.35 (Low, High, Low)

Guideline for extubation

PaO2 > 60 mmHg with FiO2 < 50% or 0.5 PEEP < 5cm RSBI = RR/Vt → RSBI < 105 good, RSBI < 80 = great No dyspnea RR < 35 P/F ratio > 150 No vasopressor or sedatives Able to follow simple orders Not agitated

Type 1 HYPOXEMIC Respiratory Failure

PaO2 LOW (< 60 mmHg), PaCO2 (normal or LOW) It involves alveolar collapse

Nursing assessment for patient receiving PD would include what to detect the most serious complication of PD?

Palpate the abdomen wall for rebound tenderness

T-piece trial

Patient is awake & alert Breathing without difficulty Gag & cough reflex intact Hemodynamically stable

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

Preload

What stage of shock is best described as the stage when mechanisms that regulate BP fail to sustain a systolic pressure above 90mmHg?

Progressive Stage

What is done to improve oxygenation in patients with ARDS?

Prone positioning

A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client?

Prone therapy

A client diagnosed with acute glomerulonephritis. This condition causes:

Proteinuria

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase?

Provide factual information and emotional support.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply.

Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level.

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary Embolism

Following cardiac surgery, the nurse assesses the client for any common complication of hypovolemia. What significant indication of a complication should the nurse monitor?

Pulmonary artery wedge pressure (PAWP) of 6 mm Hg In the presence of hypovolemia, the circulating blood volume would be significantly decreased. Therefore, the PAWP would be lower than 8 to 10 mm Hg.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position.

cardiac arrest treatment

Rapid CPR and early application of an AED. Maintain open airway, apply high concentration of oxygen, non rebreather mask.

Idioventricular Rhythm (IVR)

Rate: 20-40bpm Regularity: regular P-wave: absent QRS-complex: wide and bizarre PR-interval: absent

What is the purpose of a chest tube drainage system?

Reestablishes (NPV) Negative Pressure Ventilation, Assist w/ lung expansion & Restores normal intrapleural pressure Remember: NPV-ALE-RIP

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Respiratory alkalosis

One of the body's mechanisms of compensation on this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do?

Restores BP

Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch.

Restrictive cardiomyopathy (RCM)

A nurse is conducting a health history on a client with a primary diagnosis of mitral stenosis. Which disorder reported by the client is the most common cause of mitral stenosis?

Rheumatic endocarditis

What is the most common cause of mitral stenosis?

Rheumatic endocarditis

It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the:

Right ventricle to the right atrium.

What 2 values would you check to ensure patient is oxygenating?

SpO2 (oxygen saturation) & ABG SaO2

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply.

Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway High pressure alarm = obstruction

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family?

Sweating Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Take daily weights A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

During preshock, compensatory stage of shock, the body via SNS stimulation, will release catecholamines to shunt blood from one organ to another. Which organ will always be protected?

The brain

A nurse is caring for a client who's ordered CAPD. Which finding should lead the nurse to question the client's suitability for CAPD?

The client has a history of diverticulitis

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit?

The client is going into cardiogenic shock.

The final pathway of all shock states resulting in end organ dysfunction and death is when

The compensatory mechanisms fail to restore physiologic balance

A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.

Tracheal ischemia Tracheal bleeding Pressure necrosis

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Traction with weights and pulleys

What are the external (fluid loss) risk factors (causes) for hypovolemic shock?

Trauma Surgery Vomiting Diarrhea Diuretics Diabetes insipidious

Indication for cardioversion

Treatment of tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells in patients that are symptomatic. (unstable a-fib, unstable a-flutter, stable v-tach)

Shunting & V/Q mismatching are common causes of which type of respiratory failure?

Type 1 Hypoxemic Respiratory Failure (PaO2 < 60 mmHg, paCO2 normal or < 35 mmHg)

In which type of respiratory failure do patients who are breathing room air commonly have hypoxemia?

Type 2 Hypercapnic Respiratory Failure (paCO2 > 50 mmHg, PaO2 < 60 mmHg)

A nurse is aware that the diagnostic feature of ARDS is sudden:

Unresponsive arterial hypoxemia.

Which clinical finding should a nurse look for in a client with chronic renal failure?

Uremia (the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure.)

Which parameters will you use to determine if client is developing sepsis?

Urine output Bilirubin Platelet BP RR MAP Creatinine GCS score

Assessing a client shortly after living donor kidney transplant surgery. Which postoperative finding just the nurse report to the physician immediately?

Urine output of 20mL/hr

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply.

Use an intravenous controller or pump. Verify dosage and pump settings with another RN. Measure urine output every hour. Deliver via CENTRAL line NOT peripheral line

How should vasoactive medications be administered?

Using a central venous line

In the compensatory stage of shock the nurse understands that the blood vessels

Vasoconstrict and shunt blood to organs leading to a decrease in urine output (<30mL/hr), increase in HR, & increase in blood glucose levels

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

Venous pooling in the extremities Bradycardia Warm skin

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?

Venous thromboemboli

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricular assist device (VAD)

During electrical cardioversion, the defibrillator is set to synchronize with the electrocardiogram (ECG) so that the electrical impulse discharges during

Ventricular depolarization

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? Sustained asystole Supraventricular tachycardia Atrial fibrillation Ventricular fibrillation

Vfib!

Which of the following clinical manifestations would the nurse expect to find in the client diagnosed with aortic regurgitation?

Visible neck vein pulsations

weaning criteria for mechanical ventilation

Vital capacity: 10 -15 mL/kg MIP @ least -20cmH2O Tidal volume: 7-9 mL/kg Minute ventilation: 6L/min RSBI: < 100 bpm, paO2 > 60 mmHg w/ FiO2 < 40%

The most accurate indicator of fluid loss or gain in an acutely ill patient is

Weight

A client with CRF is receiving hemodialysis. After hemodialysis the nurse knows that the client is most likely to experience

Weight loss Rationale: CRF causes loss of renal function thus the client retains fluid. Hemodialysis removes this fluid causing weight loss.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further.

The earliest sign of serious impairment of brain circulation related to increased ICP is:

a change in consciousness

In IMV, the nurse knows that the ventilator delivers:

a combination of assisted (machine) + spontaneous (patient) breaths

In aortic regurgitation, you will hear a systolic or diastolic murmur? and where?

a diastolic murmur at the 3/4th ICS (L sternal border) think: Re--D

What is autonomic dysreflexia?

a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency; it occurs AFTER spinal shock has resolved; the symptoms are severe headache, diaphoresis, nausea, nasal congestion, goose bumps, and bradycardia

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?

a mask

A client diagnosed with an abdominal aortic aneurysm will be most likely have

a palpable pulsatile mass on the abdomen

The nurse is obtaining a history from a client diagnosed with hypertrophic cardiomyopathy. What information obtained from the client is indicative of hypertrophic cardiomyopathy?

a parent with the same disorder only cause of hypertrophic cardiomyopathy = genetics

An operating room nurse is caring for a client who is having a pacemaker implanted. The health care provider has requested a demand mode pacemaker for this client. What is this type of pacemaker?

a self-activated PM

Burn shock is characterized by which of the following?

capillary leak

When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be

captured

A patient has had cardiac surgery and is being monitored in the intensive care unit (ICU). What complication should the nurse monitor for that is associated with an alteration in preload?

cardiac tamponade

in hypertrophic cardiomyopathy you would expect

caused only by genetics diastolic dysfunction asymptomatic until incident normal chest x ray thick enlarged Lventricular wall on echo avoid 3 D's (digoxin, dilators, diuretics)

mitral valve regurgitation (MVR) does what?

causes a backflow of blood from the L ventricle to L atrium. the backflow can lead to dilation/hypertrophy of L atrium and pulmonary edema/pulmonary congestion (HF).

A client is diagnosed with dilated cardiomyopathy. What is the most likely cause of the client's condition?

chronic alcohol use disorder

During diastole, the aortic valve is

closed (tricuspid and biscupid open )

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma GCS of 7 or less = coma (GCS of 6 = severe TBI) GCS of 3 = the lowest score, severe coma GCS of 15 = alert & awake

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?

consolidation

signs & symptoms of impending rupture of aortic aneurysm

constant, severe back or abdominal pain hypotension decreased h&h, hematocrit

As the first priority of care, a patient with a burn injury will initially need:

establish airway patency

The nurse is working with a client who asks what diagnostic studies will be done because of a suspected diagnosis of mitral stenosis. What studies will the nurse teach the client? Select all that apply. exercise test electrophysiological studies cardiac catheterization electrocardiography complete blood count

exercise test cardiac catheterization electrocardiography

Chest tube drainage works by:

gravity

During auscultation of a client, the nurse suspects a diagnosis of mitral valve regurgitation when hearing which of the following?

high-pitched blowing sound at apex

In severe flail chest the nurse knows to prep the patient for

immediate ET tube intubation & mechanical ventilation to stabilize chest wall, improves alveolar ventilation, and decreases WOB to improve intra thoracic volume

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

intracerebral hematoma

Hypovolemic Shock is characterized by

intravascular volume loss, hemorrhaging, fluid loss ...S&S include a rapid, weak pulse; low blood pressure; a change in mental status; cyanosis; cool, clammy skin; and an increased respiratory rate.

One of the most common causes of mitral valve regurgitation in people living in developed countries is

ischemia of the left ventricle.

Why is propofol a drug of choice for intubation/mechanical ventilation?

it has a short half life which means it act quickly

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply.

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome

the mitral valve separates

left atrium from the left ventricle

A nurse is assessing a client with aortic stenosis. What type of murmur will the nurse expect to hear?

loud and rough during systole.

In assessing a patient with a MVP (Mitral Valve Prolapse), the RN expects to hear what abnormality?

mitral click upon auscultation

A nurse is caring for a client diagnosed with a mitral valve prolapse who is asymptomatic. What will nurse expect to be ordered for this client?

no treatment

in Mitral Stenosis there is an

obstruction of blood flow from Latrium to Lventricle blood pools in Latrium causing Latrium to become enlarged

During systole, the aortic valve is

opened

What 2 important things does an ABG value tell you about your patient?

oxygenation status and acid-base balance

Treatment for IVR

pacemaker therapy bc IVR is bradycardia

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management.

In order to perform cardioversion

patient MUST have a pulse bc electrical current is synchronized to patient's ECG

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with

percutaneous coronary intervention (PCI). Rationale: The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics.

Shunt is defined as

perfusion without ventilation (blood is not getting oxygenated)

Antidote for heparin overdose

protamine sulfate

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?

pulmonary crackles

Pink, frothy sputum may be an indication of

pulmonary edema

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of

pulmonary embolism

The health care provider has scheduled a client with mitral stenosis for mitral valve replacement. What condition will the nurse expect to see as a complication of mitral stenosis?

pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs.

Which valve lies between the right ventricle and the pulmonary artery?

pulmonic valve

systolic heart failure

pump failure (impaired contractility, increased afterload) "sys-pump"

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

q15minutes

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

rebound hypotension

atelectasis

refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression.

Which statement about pulmonary care for patients with respiratory failure is accurate?

regular turning helps improve V/Q matching

Early signs of low oxygenation are

restlessness and agitation

Your client has been diagnosed with mitral valve prolapse syndrome. What is an important subject to include in the client's teaching?

restriction of alcohol

the common cause of valvular diseases

rheumatic heart disease/chronic rheumatic fever

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating

sinus dysrhythmia.

Indication for a pacemaker

slow pulse formation/symptomatic bradycardia (third-degree AV block, hypotension, bradycardia)

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and a rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?

staphylococcal pneumonia (bacterial pneumonia)

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:

stasis zone of coag = deepest, most serious zone of heyperemia = least serious

in mitral regurgitation what kind of murmur is heard

systolic blowing sound at apex

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? Tachycardia Widening pulse pressure Hypertension Irregular respiration

tachycardia Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration.

The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis?

the RR interval

The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first? The client with an open head injury The client with a basilar fracture The client with a concussion The client with a coup injury

the client with a basilar fraction Rationale: because of the possible location of the fracture at the base of the skull could because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid.

If the aortic valve could not close completely, would the diastolic pressure or the systolic pressure be affected the most?

the diastolic pressure

The Monro-Kellie hypothesis refers to which of the following?

the dynamic equilibrium between brain contents

Neurological level of spinal cord injury refers to which of the following?

the lowest level at which sensory and motor function are normal

In a patient with flail chest what happens?

the paradoxical chest movement decreases cardiac output which leads to hypotension, metabolic acidosis, tissue hypo-perfusion, hypoxia

stenosis

the valve does not open completely and blood flow through the valve is reduced

In AC/CMV mode the nurse understands that

the ventilator delivers a preset tidal volume & RR

A flail chest occurs when:

three or more ribs are broken in at least two places and the injured part bulges outward when the patient exhales (paradoxical movement)

Which of the following is the most common complication of prosthetic valves?

thromboembolism

arterial line

used to continuously measure & monitor blood pressure or obtain blood samples (ABG's). considered more accurate than traditional measures of blood pressure and does not require repeated needle punctures

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O.

regurgation

valves do not close completely, blood flows backwards

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

vasopressin

Dead Space

ventilation exceeds perfusion (no gas exchange + high V/Q ratio)

spike before QRS

ventricular pacing

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

water-seal chamber

Which condition indicates an overdose of lactulose?

watery diarrhea

ABCDEF Bundle

•Assess, prevent and manage pain •Both spontaneous awakening trials and spontaneous breathing trials daily •Choice of analgesia & sedation •Delirium: Assess, prevent & manage •Early mobility and exercise •Family engagement and empowerment

Following a coronary artery bypass graft, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiogram (ECG) strip for interpretation. In looking at the strip, what change in the QRS complex would most support the nurse's suspicion?

amplitude decrease An amplitude decrease would support the nurse's suspicion because fluid surrounding the heart, such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG.

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has a new onset of hypertrophic cardiomyopathy (HCM). What will be included on the plan of care?

an insertion of an implantable cardiac defibrillator

Distributive shock includes

anaphylactic, septic, and neurogenic shock

The nurse is discharging a client recently diagnosed with aortic stenosis (AS). What are symptoms associated with aortic stenosis?

angina, syncope, and dyspnea A triad of symptoms is associated with AS: (a) angina due to left ventricular hypertrophy and diminished coronary blood flow, (b) dyspnea due to heart failure, and (c) syncope, in particular with exertion, due to fixed cardiac output. A diastolic murmur is characteristic of aortic regurgitation, whereas a systolic ejection murmur is commonly heard with aortic stenosis.

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

anticoagulant

After ET tube intubation the nurse should do what?

assess for symmetry of chest expansion, auscultate lung/breath sounds

the most common cause of abdominal aortic aneurysms

atherosclerosis in aorta

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms?

atrial fibrillation

Spike before P wave

atrial pacing

in aortic regurgitation, blood flows

back to the left ventricle during diastole *think: Aortic --> LV*

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temperature

Which phase of acute renal failure signals that glomerular filtration has started to recover?

Diuretic phase

Inotropic agents for a client in Cardiogenic shock. Which medications would improve the client's contractility?

Dobutamine Dopamine Epinephrine

In the Refractory stage of shock the nurse understands that

There is irreversible cellular and organ damage Death is imminent

The nurse knows which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other?

Third-degree atrioventricular (AV) heart block

The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse?

An extra heart sound

A positive effect of catecholamine release during the compensatory phase of shock is

An increased arterial oxygenation

The major clinical use of dobutamine is

An increased cardiac output

Information obtained from central venous pressure and pulmonary artery pressure. Which statement references the most pertinent information regarding circulation?

"A pulmonary artery pressure provides information about pressure on the left side of the heart." PAP provides essential info about the effectiveness of the left ventricle. The left ventricle is most pertinent to circulation.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "I eat six small meals a day when I am hungry." "My food tastes bland without salt." "I cut back on going up the steps during the day." "My best time of the day is the morning."

"I cut back on going up the steps during the day." Cutting back on activity like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure.

A patient who is unconscious and requires full respiratory support will most likely be put on which ventilator mode?

AC (assist control) or CMV (controlled mandatory ventilation)

The medical plan of treatment for chronic mitral regurgitation would include medications to reduce afterload, such as:

ACE Inhibitors

A nurse reviews an ECG strip for a client who is admitted with symptoms of an acute MI. The nurse should recognize what classic ECG changes that occur with an MI? Select all that apply.

Abnormal Q-waves T-wave hyperactivity and inversions ST-segment elevations

A client with CKD has been receiving erythropoietin injections as prescribed. Which outcome would indicate to the nurse that this medication has been effective?

Absence of pallor

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

Which describes the onset phase of AKI?

Accompanied by reduced blood flow to the nephrons

A nurse is taking care of a patient with a PaCO2 > 50 & a pH < 7.35. The nurse understands that this clinical finding indicates

Acute Respiratory Failure (ARF)

What is acute kidney injury?

Acute kidney injury is defined as the abrupt loss of kidney function over hours to days with a 50% increase in BUN/act above baseline

A client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6 °F (37.6 °C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. What assessment is the nurse's highest priority?

Acute pain

You are caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? (What pharmacological intervention would be implemented?)

Administer norepinephrine as prescribed Rationale: vasopressors used if fluid resuscitation doesn't restore an effective BP & cardiac output. NorEpi is the initial vasopressor of choice.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?

Administer the third sublingual nitroglycerin tablet.

If a client has reduced peristalsis, then the nurse expects

Administration of parenteral feedings

The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)?

Afib MS=AFib

Current research suggests that patient survival (in regards to systemic shock) increases when

Aggressive therapy begins within 3 hours of identifying a shock state (especially septic shock)

A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply. aging hypertension mitral valve stenosis aortic valve stenosis diabetes mellitus

Aging HTN Aortic Valve Stenosis Major factors that determine afterload are the diameter and distensibility of the great vessels (aorta and pulmonary artery) and the opening and competence of the semilunar valves (pulmonic and aortic valves). If the client has significant vasoconstriction, hypertension, or a narrowed valvular opening, resistance afterload increases. Aging causes muscle stiffness, thus increasing afterload. Diabetes mellitus and mitral valve stenosis do not directly affect afterload.

Vtach treatment

Amiodarone or Lidocaine (if there is a pulse) Note - lidocaine is not effective for atrial arrhythmias, only ventricular ones. Cardioversion (for stabe vtach)

The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:

Anterior surface of the right side of the chest, between the fourth and fifth rib.

Aside from the carotid sinus, which other area should the nurse mention as a site of arterial baroreceptors?

Aorta

The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder?

Aortic regurgitation

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause ****increased*** preload. Which response by the student indicates understanding?

Application of antiembolic stockings Anything that assists in returning blood to the heart (e.g., antiembolic stockings) or preventing blood from pooling in the extremities will increase preload.

What lab* test is done to distinguish ARDS from cardiac origins?

BNP (BNP > 100 = bad)

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes

A client with CRF is admitted to the urology unit. Which diagnostic test results are consistent with CRF?

BUN 100 mg/dL & serum creatinine 6.5

Which of the following occurs during the third phase of acute renal failure?

Diuresis

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

Which dialysis methods are used for clients who are hemodynamically unstable?

CAVH, CVVH, CRRT

gold standard for diagnosis of aneurysms

CTA

Rhythm Analysis Steps

Calculate rate Determine regularity Assess P waves Determine PR interval Determine QRS duration

A client requires hemodialysis. Which type of drug should be withheld before this procedure?

Cardiac glycosides

What type of medications must be held prior to dialysis?

Cardiovascular medications

In the Intra stage of AKI, what is the cause?

Caused by conditions that affect the structure and function of the kidneys Some examples: nephrotoxicity, abx administered too fast or too much

In the Post stage of AKI, what is the cause?

Caused by problems with the flow of urine as it leaves the body Some examples: urinary retention, neurological, post-anesthesia

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

Cerebral edema Ischemia Infection Seizures Hyperthermia

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

Change in LOC

Patient eduction regarding a fistulae or graft includes which of the following?

Check daily for thrill or bruit Avoid compression of the site No IV or blood pressure taken on extremity with dialysis access No tight clothing

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

Chest pain & Dyspnea

three types of cardiomyopathy

DR. H Dilated "distended" systolic Restrictive "rock hard rigid" diastolic Hypertrophic "huge trophy-like" diastolic

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

An asymptomatic client questions the nurse about mitral regurgitation and inquires about continuing exercises. Which is the most appropriate response by the nurse? "Take ample rest after exercise." "Avoid any type of exercise." "Avoid strenuous exercise." "Continue exercising until mild symptoms develop."

Continue exercising until mild symptoms develop

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

The nurse is caring for a client who was admitted to the telemetry unit with a diagnosis of "rule/out acute MI." The client's chest pain began 3 hours earlier. Which laboratory test would be most helpful in confirming the diagnosis of a current MI?

Creatine kinase-myoglobin (CK-MB) level

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)

During the diuresis period of acute kidney injury (AKI), the nurse would observe the client closely for what complication?

Dehydration

The nurse would monitor a client in the diuretic phase of Acute Renal Injury for

Dehydration

The greatest risk for ESKD?

Diabetes mellitus with hypertension

A client with mitral stenosis comes to the physician's office for a routine checkup. When listening to the client's heart, the nurse expects to hear which type of murmur?

Diastolic, rumbling, low-pitched

During hemodialysis, toxins & wastes in the blood are removed by which of the following?

Diffusion

With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?

Distributive

A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure?

FINE crackles

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and change in urine clarity

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Flat, except for logrolling as needed

Clients with renal failure who are unable or unwilling to undergo hemodialysis or a kidney transplantation would choose

Peritoneal Dialysis (PD)

What is the most common complication of PD? And what would the nurse assess as a a sign of this complication?

Peritonitis (cloudy dialysate drainage, diffuse** abdominal pain, rebound tenderness ((late sign)))

What is PEEP? And what is used for?

Positive End Expiratory Pressure that Pushes the alveoli open via positive expiratory pressure. It is used to improve oxygenation & allows for lower FiO2 %

When a client who is on a ventilator is placed on SIMV, what does this mean?

SIMV is a weaning mode and the patient is being weaned off of the ventilator because this mode delivers a preset tidal volume & RR but also allows for spontaneous breaths and synchronizes with the patients breaths

Methods of weaning from ventilator

SIMV- gradually decrease the number of delivered breaths CPAP (PS+PEEP)- decreases patient's work of breathing PSV- decrease the amount of pressure support

A nurse is told in report that a patient has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

Second intercostal space, right sternal notch AS =2ICRS

Which of the following is the most sensitive indicator of renal function?

Serum creatinine

The nurse would monitor what lab value for a patient who has gone for a CT scan with contrast

Serum creatinine level

Based on the knowledge of the primary cause of ESRD, the RN knows to assess what most important indicator?

Serum glucose

Client with ESKD. The nurse is concerned that the client is developing renal osteodystrophy. It is noted that calcium level is 11 mg/dL for the past 3 days and phosphate level is 5.5 mg/dL. The RN anticipates the administration of which medication?

Sevelamer hydrochloride

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

What clinical characteristics are representative of neurogenic shock?

Signs of parasympathetic stimulation—dry, warm skin, hypotension, bradycardia** (other forms of shock are characterized by tachycardia)

A patient in the progressive stage of shock has blood in the NG tube and when connected to suction. You understand that this most likely means that

The patient has developed a stress ulcer that is bleeding

A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant?

The patient reports shortness of breath when walking.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently. Any injury from S1 - S5, client should be able to move independently without an assist device

In the compensatory stage of shock the nurse understands that which system is stimulated and what occurs

The sympathetic nervous system is stimulated thus stimulating catecholamine release and increasing cardiac contractility

A nurse is preparing a teaching plan regarding biological tissue valve replacement. What is a disadvantage of this type of valve replacement?

The valve has to be replaced frequently.

What does the nurse understand if they notice bubbling in the water seal chamber?

There is an air leak

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply.

adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator

The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will ****decrease***** preload? application of antiembolic stockings increasing activity administration of a vasodilating drug (as ordered by a health care provider) sustained elevation of the client's legs

administration of a vasodilating drug (as ordered by a health care provider)

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client?

allograft Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another.

The most important variable in gas exchange is

alveolar ventilation

What is the drug of choice for a stable client with ventricular tachycardia?

amiodorone

The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?

decreased left ventricular workload

Aortic dissection

diagnosis in which the arterial wall splits apart (separates)

Mitral stenosis murmur is a

diastolic rumble heard at apex and/or opening snap

Which is a cerebrovascular manifestation of heart failure?

dizziness

If the aortic valve doesn't close properly during diastole, does blood a) Leak into the right ventricle b) Leak out of the right ventricle c) Leak into the right atrium d) Leak out of the right atrium e) Something else.

e) something else If aortic valve doesnt close, blood leaks back into the LEFT ventricle called aortic regurgitation

A client with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The client's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of

embolic stroke Rationale: mitral stenosis --> increased risk of stroke

ET Tube placement is verified by

end tidal CO2 levels and confirmed via chest x ray

in dilated cardiomyopathy you would expect

enlarged heart on chest x ray systolic murmur at apex dilated heart walls on echocardiogram