MED SURG 2 - RESPIRATORY

P-waves are absent in atrial flutter. t True f False

true

True or False: If a patient has been in atrial fibrillation for more than 48 hours, anticoagulation is needed prior to a cardioversion due to blood clot risks. True False

true

How do we improve ventilation in pt's with Pulmonary Edema?

Lasix to remove fluid Morphine to reduce anxiety and preload Nitros for vasodilation Bronchodilator (Aminophylline) to improve ventilation Place in high fowlers with legs dangling

The nurse determines that alveolar hypoventilation is occurring in a patient on a ventilator when what happens? a. the patient develops cardiac dysrhythmias b. auscultation reveals an air leak around the ET tube cuff c. ABG results show a PaCO2 of 32 mm Hg and a pH of 7.47 d. the patient tries to breathe faster than the ventilator setting

B

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg

B

Later that evening, Mr. G. starts showing signs of respiratory distress and hypoxia.Now the low pressure alarm is triggered.What assessments and nursing interventions would you perform?

-check for leak -call RT -ambubag the pt until RT fixes

Mr. G., a 68 year old with COPD was admitted to the hospital 2 weeks ago withRLL pneumonia and atelectasis. During the course of his hospitalization, he developedrespiratory failure and required mechanical ventilation. He has and ETT in place andhas been stable for the last two days. While caring for him today, you noticed that theventilator high pressure alarm is going off frequently. Mr. G. is restless, trying to talk toyou, and has large amount of tracheal secretions. He has been positioned on the rightside for the past hour.What assessments and nursing interventions would you perform to alleviate theproblem with the high pressure alarm?

-suction secretions -bite block -sedation

SMALL BOX ON EKG

0.04 seconds

LARGE BOX ON EKG

0.2s

What is Virchow's triad?

1. Venous stasis 2. Hypercoagulability (cancer pt, nicotine, caffeine, BC, estrogen therapy, factor 5) 3. Trauma to a vessel

PT/INR levels

1.5-2.5x normal normal PT: 10-13 normal INR: 0.8 and 1.1 Therapeutic range PT: 10-13 sec INR: 2 to 3 sec

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client stops spontaneous breathing.

123

A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1.Monitor the client's temperature. 2.Use sterile technique when suctioning. 3.Use the closed-system method of suctioning 4.Monitor sputum characteristics and amounts. 5.Drain water from the ventilator tubing into the humidifier bottle.

1234

A 19 year-old patient being administered PEEP begins to have copious amounts of secretions that she says she "just cannot cough up." Which of the following nursing actions is most appropriate at this time? 1) Assess the patient further and utilize bedside suction equipment. 2) Assess O2 sats and continue to monitor patient if results are 95% or above. 3) Obtain respiratory therapy consult. 4) Obtain an order for a mucolytic agent from the physician.

3 - At this time, the nurse should obtain a respiratory therapy consult. Any break in the closed ventilator system causes the loss of PEEP, so respiratory therapy needs to be consulted to add in-line suctioning.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Ask the health care provider for a prescription for succinylcholine. 3.Encourage the client to sleep until arterial blood gas results improve. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4

A client who is diagnosed with acute respiratory distress syndrome​ (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory​ cycle? A. Positive​ end-expiratory pressure​ (PEEP) B. Sensitivity C. Flow rate D. Tidal volume​ (TV)

A

Mr. G requires neuromuscular blockade to facilitate mechanical ventilation. Which is not a true statement when providing nursing care to paralyzed patients? A) Because patients under neuromuscular blockade are unable to react to the environment, special safety precautions are not needed. B) Pain medication is required because neuromuscular blocking agents do not have an analgesic effect. C) Patients under the influence of neuromuscular blocking agents are fully aware of activity around them. D) The nurse must be alert for complications of immobility such as deep vein thrombosis, pressure ulcers, and atelectasis.

A

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes.

A

What are possible causes of Sinus Tachycardia? Select all that apply: A. Exercise B. Atropine C. Pain D. Sick Sinus Syndrome E. Cardiogenic shock F. Hypothyroidism

A B C E

You're analyzing an ECG strip. In order for the rhythm to be identified as Sinus Tachycardia, what must be present in the rhythm? (Select all that apply): A. One p wave present in front of every QRS complex B. Atrial rate >100 bpm C. Ventricular rate >100 bpm D. Regular atrial rate and irregular ventricular rate E. Regular atrial and ventricular rate F. Atrial rate <60 bpm G. QRS complex <0.12 seconds H. PR interval 0.12-0.20 seconds I. PR interval >0.20 seconds

A B C G E H

Atropine was ineffective for treating the bradycardia. The patient is still symptomatic with a rate 35 bpm. What other options could be considered for the patient? Select all that apply: A. Transcutaneous pacing B. Amiodarone Infusion C. Dopamine Infusion D. Epinephrine Infusion

A C D

Select the options below that describe Vtach A. Monomorphic B. Regular atrial rhythm C. QRS complex >0.12 seconds D. Irregular ventricular rhythm E. Regular ventricular rhythm F. Ventricular rate >100 bpm G. Atrial rate >80 bpm H. Polymorphic I. Ventricular tachycardia J. Ventricular fibrillation

A C E F I

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

A ~ Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What interventions will most likely decrease the risk of accidental extubation? Select all that apply a. administer sedatives b. have a caregiver stay with the patient c. obtain an order and apply soft wrist restraints d. remind the patient that he needs the tube inserted to breathe e. move the patient to an area close to the nurse's station for closer observation

A, B

A unconscious client is admitted to the intensive care unit (ICU) and placed on mechanical ventilation after sustaining a traumatic brain injury (TBI). Which nursing action is appropriate in the provision of care for this client? Select all that apply. A Assess the client for any implanted devices. B Complete head to toe assessment C Look for medical alert bands D Remove contacts if no eye trauma is present.

A, B, C, D Certain implanted devices are contraindicated for diagnostic procedures; therefore, this nursing action is appropriate in the provision of care for this client. A complete head to toe assessment is required upon admission to the hospital. This data is used to plan care and enhance the client's safety during hospitalization. Medical alert bands provide the nurse with information that enhances safety when providing care to an unconscious client; therefore, this nursing action is appropriate in the provision of care for this client. Make sure client belongings are properly secured. It is essential to secure all belongings when a client is admitted to the hospital for care. Contact lenses are removed from the client after it is determined that no eye trauma is present as this action decreases the risk for corneal abrasion; therefore, this nursing action is appropriate in the provision of care for this client.

The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare​ provider?(Select all that​ apply.) A. Agitation B. Pallor C. Oxygen saturation level of​ 98% D. Respiratory rate of 18​ beats/min E. Abdominal breathing

A, B, E

You're analyzing a patient's ECG reading. What should be found in the rhythm for it to be considered Sinus Bradycardia (select all that apply): A. One p wave present in front of every QRS complex B. Atrial rate 60 and ventricular rate of 60 C. Regular atrial and ventricular rate D. Atrial rate 40 and ventricular rate of 40 E. Regular atrial rate and irregular ventricular rate F. PR interval 0.14 seconds G. PR interval 0.36 seconds H. QRS interval 0.08 seconds I. QRS interval 0.16 seconds

A, C, D, F, H

Which intervention should the nurse implement to decrease the risk for aspiration when providing care to a client who is on a ventilator and receiving feedings via a nasogastric tube (NGT)? Select all that apply. A Check the client for abdominal distention with every assessment. B Aspirate and measure gastric residual every 8 hours. C Maintain the client in a semi-Fowler position at all times. D Perform weekly sedation vacations to assess mental status. E Give lorazepam 0.5 mg to 1 mg intravenous push (IVP) for anxiety as prescribed.

A, C, E Gastric residual should be measured and aspirated q4hrs Sedation decreases gastric emptying and increases the risk for aspiration; therefore, sedation should only be administered as prescribed for the client who is at risk for aspiration.

The nurse provides care for a client who is sedated, and receiving mechanical ventilation. Which intervention should be included in the client's nursing plan of care? A. Complete daily sedation vacations. B. Mute ventilator alarms. C. Keep a bag-valve-mask near the bedside at all times. D. Keep HOB at 15 degrees E. Delegate oral care every two hours to the unlicensed assistive personnel (UAP).

A, C, E Ventilator alarms should never be muted as they may indicate life-threatening complications; therefore, this is not an intervention that should be included in the client's nursing plan of care. The head of the bed should be kept at 30-45 degrees to reduce the risk of aspiration and further infection; therefore, this not an appropriate intervention to include in this client's nursing plan of care.

Select the options below that best describe NSR above: A. Regular atrial rhythm B. Irregular ventricular rhythm C. PR Interval < 0.20 seconds D. QRS complex > 0.12 seconds E. Equal atrial and ventricular rate F. Atrial rate > than ventricular rate G. First-Degree Heart Block H. Sinus bradycardia I. Normal Sinus Rhythm

A, C, E, I

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? a. Dizziness and syncope b. Shortness of breath (SOB) worsening over the last 2 weeks c. Inspiratory chest pain d. Productive cough e. Pink, frothy sputum f. Tachycardia (dizziness, syncope, hypotension, and fainting, sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are characteristic of PE)

A, C, F

What are the nursing interventions to decrease risk for pulmonary embolism of postoperative patients? a. Start passive and active ROM exercises for the extremities b. Ambulate postoperative patients soon after surgery c. Use anti embolism devices postoperatively d. Elevate legs in an extended position e. Change patient position every 4-5hrs (change position every 2 hours)

A-D E is wrong because we want to move q2hrs

The nurse provides teaching to the spouse of a client receiving mechanical ventilation via endotracheal tube (ETT). Which statement by the spouse alerts the nurse that further teaching is necessary? A My partner will be suctioned after the nurse performs mouth care each hour. B The nurse will listen to my partner's neck to check for leaks in the endotracheal tube. C I should expect the nurse to suction my partner, and complete oral care, every two hours per hospital protocol. D The nurse will change my partner's position at least every two hours.

A. Evidence-based practice (EBP) guidelines indicate that clients who are intubated with an ETT and mechanically ventilated are suctioned every 2 hours, not hourly; therefore, this statement indicates a need for additional teaching.

Is it normal to see bubbles in the chamber of a chest tube system?

It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles.

A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b. Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan) d. Increase the rate for the ordered propofol (Diprivan) infusion.

B

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings.

B

A nurse is caring for an agitated and anxious patient who was intubated 6 hours ago and is now on mechanical ventilation. Communication efforts to calm the patient have failed, and the nurse is now turning to pharmacological intervention. Which medication does the nurse anticipate administering? 1) Lorazepam 2) Morphine sulfate 3) Pancuronium 4) Fentanyl

Although Pancuronium (a neuromuscular blocking agent) CAN be used, it is best to try a sedative first. If satisfactory oxygen levels still cannot be maintained, then a neuromuscular blocking agent (WITH PAIN MEDICATION AND SEDATION!) can be used.

Pt with afib/flutter and s/s low cardiac output. Tx?

Antiarrhythmic - Amiodarone or Cardioversion to convert rhythm. Calcium Channel blockers or digoxin to treat rate

A patient has the following blood gases: PaCO2 25, pH 7.50, HCO3 19. Which of the following could NOT be the cause of this condition? A. Anxiety attack B. Chronic obstructive pulmonary disease (COPD) C. Fever D. Aspirin toxicity

B

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems.

B

Your patient is unresponsive and the cardiac monitor shows Torsades de Pointes as the patient's rhythm. As the code team is attempting to resuscitate the patient, you look through the patient's electronic health record to try to determine a potential cause for this rhythm. What found in the patient's record is a cause of this rhythm? A. Magnesium level 2 mg/dL B. Amiodarone C. Potassium 5 mEq/L D. Glyburide

B

The patient is experiencing the rhythm above. The patient is presenting with a blood pressure of 70/42, mental status changes, and is clammy and pale. A pulse is present. The nurse preps the patient for? A. CPR B. Synchronized cardioversion C. Defibrillation D. Atropine IV

B ONLY DEFIB WHEN NO PULSE. IF STABLE - AMIODARONE IF UNSTABLE - CARDIOVERT

Your patient is experiencing Sinus Tachycardia with a rate of 160 bpm. Which findings below demonstrate the patient is experiencing a decrease in cardiac output? Select all that apply: A. Blood pressure 220/120 mmHg B. Blood pressure 70/42 mmHg C. Crackles throughout the lung fields D. Decreased capillary refill time E. Cool extremities

B C E

What complications can develop from uncontrolled atrial fibrillation that the nurse should monitor for? Select all that apply: A. Hypertension B. Stroke C. Heart failure D. Hyperglycemia

B, C Atrial fibrillation leads to incomplete atrial contraction that causes the atria to quiver. This can lead to blood pooling in the atria. When blood pools it coagulates (hence forms clots). The clots can break off and travel through the body leading to a stroke. In addition, if the rate if too fast (not controlled) the heart's ability to pump blood throughout the body fails because it becomes overworked and tired. This leads to heart failure.

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? Select all that apply a. Vomiting b. Cyanosis c. Rapid heart rate d. Dyspnea e. Paradoxical chest movement f. Crackles in the lung fields

B, C, D

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? Select all that apply a. assist-control b. synchronized intermittent mandatory ventilation c. continuous positive airway pressure d. pressure support ventilation e. independent lung ventilation

B, C, D

What other medications can be administered to a patient experiencing Ventricular fibrillation (V-fib) during a code resuscitation attempt? Select all that apply: A. Atropine B. Epinephrine C. Amiodarone D. Lidocaine

B, C, D

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

B, C, D, E

The nurse provides care for a client who is intubated and mechanically ventilated in the intensive care unit (ICU). Which action should the nurse implement to decreases this client's risk for developing ventilator associated pneumonia? Select all that apply. A. Endotracheal suctioning every two hours and PRN B. Implement a ventilator weaning protocol C. Keep head of bed elevated at least 15 degrees at all times D. Performing mouth care with approved antiseptic solution E. Wear clean gloves when providing client care

B, D, E Frequent suctioning should only be performed when clinically indicated such as adventitious breath sounds, coughing, and elevated airway pressures; therefore, this action should not be implemented by the nurse as it increases, not decreases, the client's risk for ventilator associated pneumonia. The head of the bed should be maintained in a semirecumbent position, which is approximately a 30 to 40 degree angle; therefore, this is not an action the nurse implements for this client to decrease the risk for ventilator associated pneumonia.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? Select all that apply a. confusion b. pale skin c. bradycardia d. hypotension e. elevated blood pressure

B, E

Which patient's medical diagnoses should the nurse know are most likely to need mechanical ventilation? Select all that apply a. sleep apnea b. cystic fibrosis c. acute kidney injury d. type 2 DM e. acute respiratory distress syndrome (ARDS)

B, E

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? a. Teach the client to avoid using dental floss. b. Monitor the platelet count daily. c. Ensure adequate staffing for the unit. d. Notify radiology of an impending scan.

B. Monitor the platelet count daily

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? a. "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." b. "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." c. "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." d. "If bleeding develops, we will give platelets to reverse the anticoagulant."

B. Therapy with warfarin (Coumadin) is effective when INR is between 2 and 3.

Pt with tachycardia, His vital are now BP 140/90, HR 110, RR 26,temperature 101.1o degrees F. What medicine would you give? Patient has prn order for Tylenol (acetamenophen), and standing arrhythmia orders for Atropine, and Cardizem.

BP is good and no s/s decreased cardiac output so he wouldn't need to treat the arrhythmia with Cardizem at this point. Give anti-pyretic.

A patient attempted to commit suicide by ingesting a bottle of Aspirin. Which of the following conditions is this patient at risk for? A. Hyperkalemia B. Hypercalcemia C. Respiratory alkalosis D. Respiratory acidosis

C

A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote vasodilation. What should the nurse recognize about the care of this patient? a. the patient will be too sedated to be aware of the details of care b. caregivers should be encouraged to provide stimulation and diversion c. the patient should always be addressed and explanations of care given d. communication will not be possible with the use of neuromuscular blocking agents

C

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? a. Administer ordered antibiotics as scheduled. b. Hyperoxygenate the patient before suctioning. c. Maintain the head of bed at a 30- to 45-degree angle. d. Suction the airway when coarse crackles are audible

C

The nurse sees the rhythm above on the ECG. The patient is unresponsive and has no pulse. The nurse calls a code blue and takes what step next? A. Prepare for defibrillation B. Administer Epinephrine C. Start high-quality CPR D. Notify the physician

C

The nursing management of a patient with an artificial airway includes a. maintaining the ET tube cuff pressure at 30 cm H20 b. routine suctioning of the tube at least every 2 hours c. observing for cardiac dysrhythmias during suctioning d. preventing tube dislodgment by limiting mouth care to lubrication of the lips

C

Select the options below that describe AFlutter A. P-waves present B. Fibrillary waves present C. Flutter waves present D. Atrial rate <100 bpm E. QRS complex less than 0.12 seconds F. PR interval <0.20 seconds G. Atrial fibrillation H. Atrial flutter I. Normal sinus rhythm

C E H

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.

C ~ When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acid. c. Exercise on a regular basis. d. Maintain a healthy weight e. Stop smoking cigarettes.

C, D, E ~ Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.

D

Which of the following is not a cause of respiratory acidosis? A. Pulmonary edema B. Asthma C. Chronic obstructive pulmonary disease (COPD) D. Hyperventilation

D

Select the options below that describe VFib rhythm: A. Irregular atrial rate B. Regular ventricular rate C. Fine fibrillatory waves D. Coarse fibrillatory waves E. Torsades de Pointes G. Asystole H. Ventricular tachycardia I. Ventricular fibrillation

D, I

A client who is diagnosed with emphysema is prescribed non-invasive positive pressure ventilation (NIV). The following medications are due at 0900: Salmeterol inhaler 4 puff; Vancomycin 1 gm IVPB; Prednisone 10 mg PO; and Enoxaparin 80 mg SQ. Which is the most important assessment to perform for this client?

LEVEL OF CONSCIOUSNESS Pt must be able to spontaneously breathe

Failure to capture (pacemaker)

Failure to capture means that the ventricles fail to response to the pacemaker impulse. On an EKG tracing, the pacemaker spike will appear WITH P WAVE but it will not be followed by a QRS complex.

Heparin protocol

Give loading dose Then IV Drip Titrate based off 1.5-2.5x baseline PTT Normal PTT is 25-35 sec Therapeutic range = 37-88 sec Below <37 = increase dose Above >88 = decrease dose ANTIDOTE - PROTAMINE SULFATE

After Heparin, pt is started on Warfarin/Coumadin

Given simultaneously with Heparin to overlap 4-5 days Takes 36-72hrs before therapeutic level is reached Monitor PT/INR level OP - DC only after INR is therapeutic Continue taking for 3-6 months ANTIDOTE - VITAMIN K Teach to avoid leafy greens, green tea, OP lab monitoring, no contact sports

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? a. Inadequate nutrition related to food-drug interactions with anticoagulant therapy b. Risk for infection related to leukocytosis c. Hypoxemia related to ventilation-perfusion mismatch d. Insufficient knowledge related to the cause of PE

Hypoxemia related to ventilation-perfusion ratio

Indirect vs Direct causes of ARDS

Indirect - without lung injury (sepsis, blood tx, pancreatitis) Direct - lung injury (drowning, aspiration, PNA)

Lovenox

Low Molecular Weight Heparin (LMWH); Anticoagulant Given subcutaneously "Enoxaparin is given subcutaneously in the love handles, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate." Alternate injection sites Assessing the clients platelet count. Not aspirating prior to injection. Swabbing the injection site with alcohol

cardioversion nursing considerations

Monitor patient VS, administer sedation and analgesia, apply pads, monitor skin for burns after pads removed

The physician has ordered the patient to receive Pavulon, a neuromuscular blockingagent.What do you tell Mr. J and his family about this medication?

Neuromuscular blockers paralyze all muscles so that the patient can't move and buckthe ventilator. Allowing the ventilator to ventilate the patient is very important. Thismedication does not alleviate pain and the patient's sensation and cognition is intact. Soin addition to the neuromuscular blocking agent the patient will need pain medicationand be heavily sedated.

Chest tube management

Never clamp. Lower than the bed. Tape all connections. Look for bubbling in the chamber & tidaling with every breath.

Mr. J was admitted with respiratory failure and intubated several hours ago. The Ventilator mode is AC with a rate of 14. The high pressure alarm is continually alarming. You note that he is anxious and "bucking" the ventilator. What should you do?

Patient needs sedation and maybe a NMBA. Administer prn sedation or call physicianfor an order. If patient continues to "buck" the ventilator then notify the physician who willmost likely order a NMBA.

What is train of 4 testing for mechanically ventilated patients?

Patients who require long term neuromuscular blockade must be closely monitored to prevent complications such as prolonged skeletal muscle weakness. The patient's level of paralysis is assessed with a peripheral nerve stimulator (PNS). This is a device that delivers an electrical stimulus to a preselected nerve. Usually the ulnar nerve. The methods of testing the level of paralysis include single, tetanic, and train-of-four (TOF). TOF is the most common and involves delivering four consecutive electrical stimuli. When the ulnar nerve is used, the expected response is twitches of the thumb toward the hand. The number of twitches corresponds to the level of paralysis.

Young female no risk factors w/PE. What teaching?

Possible testing for factor V Leiden (inherited condition)

How would you explain to the patient what to expect during the VQ scan?

Radio isotope inhaled and injected IV

Justin, 18 yr old college student, reported to the Student Health Clinic with c/o feel dizzy and SOB. His vital signs are BP 92/50, HR 45, RR 22, Sinus Brady. How should we treat?

S/S of low cardiac output = becoming unstable, give atropine. if no s/s = nothing if unstable = transcutaneous pacing

Why do we give pain meds after ventilation?

Sedatives reduce many of the emotional signs of pain, medical personnel may overlook the fact that the patient is still experiencing the physical component of pain. Intravenous narcotics are the analgesic of choice for this patient population because they exert their effect on the central nervous system, rather than only the peripheral pain receptors. Morphine is preferred unless the patient has cardiovascular instability. In this case, the patient may not tolerate the transient hypotension produced by morphine-related histamine release, so fentanyl (Sublimaze) or hydromorphone (Dilaudid) can be used instead.

what can cause PVC's

Stimulants, hypoxia, electrolyte imbalance

Contraindications for tPA administration

Stroke w/in last 2 months Recent surgery Active bleeding

tachyarrhythmia can occur with

Sympathetic NS stimulation. Give meds to block sympathetic nervous system stimulus. (adenosine, metoprolol)

The nurse provides care for a client who is mechanically ventilated. The client is experiencing quickly decreasing oxygen saturation levels and the ventilator is alarming, "low tidal volumes." Which is the priority action by the nurse to address the current client issue?

The client who experiences rapidly decreasing oxygen saturation levels in addition to the ventilator alarm, "low tidal volumes" is not receiving adequate respirations from the ventilator. The priority action by the nurse is to oxygenate the client using the BVM.

What other interventions are warranted for this patient while receiving neuromuscular blocking agents?

The patient will be entirely immobile - not even able to open and shut his eyes. Care must be taken to perform PROM exercises, prevent skin breakdown and assure that his eyes are well lubricated and closed and covered.

How do we properly suction a ventilated client?

The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.

vagal maneuvers examples

Valsalva, coughing, carotid massage, cold stimulus to the face. Helps to stimulate the PARASYMPATHETIC RESPONSE.

Why do we give dopamine?

When BP is too low <90 Give dopamine = vasoconstrictor that increases preload

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find?

When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.

Explain ARDS

alveolar capillary membrane permeability has changed leading to fluid collection in alveolar sacs

unstable 2nd heart block

give atropine or transcutaneous pacing

sedatives post RSI

most common: Ativan, Versed, Propofol These drugs decrease anxiety and produce amnesia, but they don't relieve pain. midazolam (Versed) and propofol (Diprivan), can cause cardiac depression.

NMBA post RSI

most common: cisatracurium (Nimbex), atracurium (Tracrium), pancuronium (Pavulon), vecuronium (Norcuron)

failure to sense (pacemaker)

pacer sends a pace spike when it shouldn't, unnecessary pacer spikes can cause a R on T phenomenon

Hallmark s/s of pulmonary edema

pink frothy sputum and crackles at the bases of the lungs dyspnea on exertion, paroxysmal nocturnal dyspnea orthopnea, cough

NMBA MUST ALWAYS BE GIVEN WITH

sedative & narcotic MUST MONITOR BP AND HR

sedatives & nmba for RSI

sedative: etomidate and ketamine nmba: rocuronium, succinylcholine