Perfusion II Quizlet
A, B The nurse would want to place the patient on their side (preferably the left-side...not supine) to help prevent the tongue from obstructing the airway, preventing aspiration, and improving blood flow to the placenta. In addition, the nurse would NOT want to restrain the patient, which can cause injury.
A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure? A. Placing the patient in a supine position B. Holding down the patient's head to prevent injury C. Staying with the patient and activating the emergency response team D. Timing the seizure E. Providing 8 to 10 L of oxygen
A, B, C, E Smoking cessation or reduction should be encouraged. However, it is not right because the use of tobacco is not a direct cause of hypertension.
A client has recently been diagnosed with hypertension. Which intervention should the nurse include in the plan of care? SATA A. Teaching the client about the health benefits of regular exercise B. Encouraging the client to perform stress reduction techniques C. Assisting the client to set a goal for a healthy weight D. Encouraging the client to reduce smoking E. Teaching the client how to adhere to the DASH diet
B, C, E The other answer choices are NON modifiable risk factors.
A nurse is discharging a patient that was recently diagnosed with coronary artery disease. What modifiable risk factors will the nurse talk about? SATA A. Age B. Diabetes control C. Limit or reduce stress D. Gender E. Exercise
A, D, E These are all the correct teaching points for mitral valve prolapse. B and C are unrelated.
A nurse is discussing lifestyle changes with a 23 year old female patient who was diagnosed with Mitral Valve Prolapse. Which of the following do you suspect the nurse is mentioning? SATA A. Limit alcohol intake B. Participate in vigorous exercise 3 times per week C. Increase intake of green leafy vegetables D. Control anxiety with deep breathing and meditation E. Eliminate caffeine and tobacco
A. Treat the pain and instruct the patient to bear down. We want to ID the rhythm, assess our patient, and then treat the cause. In this case, severe pain in the cause of the sinus tachycardia the pain is treated first. If bearing down (vagal maneuver) does not work, then adenosine might be an option.
A nurse is reading an EKG strip for a patient that was admitted to the emergency room for severe pain. What action do you anticipate the nurse will make? A. Treat the pain and instruct the patient to bear down B. Push adenosine C. Continue to monitor the patient D. Call a code and prepare for defibrillation
B Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.
A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient? A) Chest pain B) Bleeding at the implantation site C) Malignant hyperthermia D) Bradycardia
A Atropine is administered at 0.5mg for symptomatic sinus bradycardia pts (chest pain or low BP) every 3-5 mins up to 3mg. What are the side effects? Hint: can't ***, can't ***, can't ****, can't ****
A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D) Administer atropine 1.0 mg sublingually.
B A side effect of ACE inhibitors is a dry cough.
A patient with hypertension is started on a new medication for treatment and is reporting a continuous dry cough. Which of the following medications do you suspect is causing this problem? A. Losartan B. Lisinopril C. Hydrochlorothiazide D. Labetalol
C. Due to the patient being in fluid overload (especially with left-sided heart failure...remember the lungs are majorly affected in this type of heart failure), it is most appropriate to place the patient in High Fowler's position to help make breathing easier.
A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? A. Encourage the patient to cough and deep breathe. B. Place the patient in Semi-Fowler's position. C. Assist the patient into High Fowler's position. D. Perform chest percussion therapy.
B Gestational hypertension occurs in the second half of pregnancy in a previously normotensive mother. Diagnosis is made after obtaining a BP greater than or equal to 140/90 mmHg on at least two occasions (at least 6 hours apart, after 20 weeks of gestation).
A pregnant client has a blood pressure (BP) reading of 142/90 mmHg at the 32-week prenatal visit. Upon return 1 week later, the client's BP is 152/94 mmHg. Prior to these results, the client had normal BP readings. The prenatal nurse anticipates that this client will be diagnosed with which hypertensive disorder of pregnancy? A. Eclampsia B. Gestational hypertension C. Preeclampsia D. Chronic hypertension
Replace leads every 24 hours to prevent scarring or skin breakdown. Rotate the sites and NEVERRRRR put a dirty sticker back onto the skin. Especially a wound side because this can spread infection.
How often do the leads on a patient need to be changed?
*** BEFORE STARTING: *** Please change the settings to where the definition and terms are flipped. I have some strip pictures that are inserted and the only way to go through this study set correctly is to change the settings. Happy studying!! - Ya girl, Annalise
If this is the first thing you see then wonderful. You have successfully changed the setting. YOU MAY PROCEED
B If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing to "PICK UP THE PACE" An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief.
The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Transcutaneous pacemaker C) ICD D) Asynchronous defibrillator
C Decreasing environmental stimuli helps reduce the risk of seizures that may occur for a client with preeclampsia.
The nurse has discussed methods to decrease the risk of seizure activity with a client diagnosed with preeclampsia. Which client statement indicates an understanding of the teaching? A."I will keep my legs elevated." B."I will let you know if I do not feel my baby move." C."I will make sure everything is quiet." D."I will not lay flat on my back
1, 2, 3, 4 Clients with severe preeclampsia are maintained on bed rest in the lateral position. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.
The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.) Keep the room semi-dark. 2.) Initiate seizure precautions. 3.) Pad the side rails of the bed. 4.) Avoid environmental stimulation. 5.) Allow out-of-bed activity as tolerated.
D HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.
The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome? A) Hyperglycemia B) Elevated platelet count C) Leukocytosis D) Elevated liver enzymes
D All discharge medications are still needed after the pacemaker is implanted.
The nurse is teaching the client with a new permanent pacemaker. Which statement by the client indicates the need for further discharge education? a. "I will be able to shower again soon." b. "I need to take my pulse every day." c. "I might trigger airport security metal detectors." d. "I no longer need my heart pills."
C The QRS complex represents ventricular depolarization (contraction).
The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A) P wave B) T wave C) QRS complex D) U wave
A, C, D, E During the client interview, the nurse should ask the client about the presence of preeclampsia complications, including headache, changes in vision, presence of swelling in face or hands, dizziness, and seizures. Diarrhea is not characteristic of preeclampsia, so this question would not be necessary to ask.
The prenatal nurse is completing an assessment of a pregnant client at 36 weeks of gestation who has preeclampsia. Which question is important for the nurse to ask during the assessment? (Select all that apply.) A."Have you noticed any changes in your vision?" B."Have you had any episodes of diarrhea?" C."Have you noticed any swelling in your hands or face?" D."Have you had any headaches?" E."Have you experienced any seizures?"
A, C, D These are all possible causes of Sinus Tachycardia.
What are possible causes of Sinus Tachycardia? Select all that apply: A. Exercise B. Valsalva maneuver C Atropine D. Pain E. Hypothyroidism
ASSESS YOUR PATIENT! A high rate of triggered, clinically insignificant alarms may lead to alarm fatigue which has been linked to nurses disabling them. This puts pts at risk for adverse effects.
What is an appropriate action by a nurse when an alarm is sounding off in a patients room?
120 bpm Sinus Tachycardia
What is the rate? What is the rhythm?
B, D, F Persistent cough, crackles, and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.
Which of the following are NOT typical signs and symptoms of right-sided heart failure? SATA A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea
B. Spironolactone is potassium-sparing. Therefore, it can increase the potassium level (hyperkalemia).
Which of the following is a common side effect of Spironolactone? A. Renal failure B. Hyperkalemia C. Hypokalemia D. Dry cough
A. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A) Calcium gluconate B) Potassium chloride C) Ferrous sulfate D) Calcium carbonate
B. The best answer for this particular question is option B. All the options are important for the nurse to perform. However, Hydralazine and Lasix can cause orthostatic hypotension. The patient should transfer slowly and gradually to decrease dizziness and the risk of falling.
You are assisting a patient up from the bed to the bathroom. The patient has swelling in the feet and legs. The patient is receiving treatment for heart failure and is taking Hydralazine and Lasix. Which of the following is a nursing priority for this patient while assisting them to the bathroom? A. Measure and record the urine voided. B. Assist the patient up slowing and gradually. C. Place the call light in the patient's reach while in the bathroom. D. Provide privacy for the patient.
C. Assess the patient Assess the patient. When discovering sinus bradycardia, the nurse should determine if the patient is having symptoms. Not all cases of this rhythm require medical treatment.
You obtain an ECG on a patient and review the strip. Your NEXT nursing action is to? A. Prepare to administer Atropine IV push B. Set-up for transcutaneous pacing C. Assess the patient D. Call a rapid response
D. Patients with HF should limit sodium intake to 2-3 grams per day (not 5-6 grams), avoid canned vegetable/fish, and avoid sandwich meats and cheeses because of their high sodium content. Frozen meals are high in sodium, therefore the patient is correct in saying they should limit their consumption of them.
You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals."
