Med Surg 2 review exam 1

S/S of anaphylactic shock?

Give pt medication and 20 minutes goes by what are the s/s youll see? Hives, rash, SOB, Low BP, tachycardia

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001

Hct 55%

Which of the following is an action caused by epinephrine in anaphylaxis? Decreased heart rate Vasoconstriction Bronchoconstriction All of the above

Vasoconstriction

Pt has neurogenic shock what are the prescriptions you anticipate giving to pt? (Select all that apply)

Vasopressors - Norepinephrine, dopamine - To treat hypotension Antimuscarinic - Atropine - To treat bradycardia IVF

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

d. SV x HR

Which of the following is NOT a side effect of epinephrine? Pallor Vomiting Bradycardia Chest pain

Bradycardia

DIC? What is it- whats happening in the body?

DIC is: Abnormal coagulation occurs, but then all our blood clotting "fibrinogen, platelets" rushing into the area and forming clots, but then depleting in another area of the body and causing hemorrhage. So, we have clotting on one site, and at another site we have bleeding.

If pt is in V-fib and unresponsive, what should the nurse do?

Defibrillating them CPR (this would be correct but answer on exam is defib them)

Palpitations with V-tach, symptomatic (lightheaded dizzy) but sitting up talking to nurse; and showing runs of V tach. What would a nurse do for that pt?

cardioversion

Cardiogenic shock -

(↓BP, ↓ MAP, Tachycardia, agitation and restlessness, "cold and clammy skin", ↓ urinary output) circulatory failure and hypoperfusion caused by some form of cardiac dysfunction. Cardiac dysfunction causes myocardial ischemia, which leads to decreased myocardial contractility. This decrease in contractility results in decreased CO and systemic hypoperfusion.

PAC

*Extra beat* Regularity: interrupts regularity of underlying rhythm Rate: depends on underlying rhythm P wave: different morphology from rhythm, possibly hidden behind T wave PRI: 0.12-0.20 if measurable QRS: less than 0.12

If client is experiencing frequent PVC (premature ventricular contractions), what will HR be?

*Irregular / wide QRS* a. Regularity: Irregular b. Rate: depends on underlying rhythm c. P wave: NA d. PRI: NA e. QRS: greater than 0.12 *extra, wide complex QRS* f. PVCs are on a different rhythm g. More often PVCs it will be more obvious that it is irregular

Septic Shock

- infection, release of inflammatory cytokines and other proinflammatory mediators (pancreatitis, burns, hospital-acquired infections)

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

0.9% sodium chloride

You're providing care to four patients. Select all the patients who are at risk for developing sepsis (SELECT ALL THAT APPLY): A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. A 55-year-old male who is a recent kidney transplant recipient. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

How do you know if pacemake is functioning properly on EKG strip?

A-paced: spike before p wave V-paced: spike before QRS

A 35-year-old female has just eaten lobster and is now complaining of itchy, watery eyes. Her blood pressure is beginning to fall, but she denies difficulty breathing. Which of the following best describes her condition? Anaphylaxis Dyspnea Shock Mild allergy

Anaphylaxis

Caring for pt with hypovolemic shock, what are some things you are going to for this pt? What is to be expected as far as your care? What do you anticipate this pt will need?

Anticipate giving blood products(First:PRBC's, other answer choices are plasma, platelets, )

What causes AAA

Atherosclerosis, HTN, infection, trauma.

A nurse is reinforcing teaching with a newly licensed nurse about reading a client's ECG tracing. The nurse should include in the teaching that the P wave represents which of the following cardiac electrical activities?

Atrial depolarization

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

Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.

a nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. the nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? a. First-degree AV block b. Atrial fibrillation c. Sinus bradycardia d. Sinus tachycardia

Atrial fibrillation disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

Atrial rate of 300/min with QRS complex of 80/min

A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit

Auscultate blood pressure for pulsus paradoxus

A nurse assigned to the intensive care unit​ (ICU) should closely monitor which client who is at most risk for septic​ shock? a A​ 66-year-old female with infectious pneumonia b A​ 22-year old male with spontaneous pneumothorax c A​ 46-year old female with mitral valve prolapse d A​ 34-year old male with a traumatic head injury

A​ 66-year-old female with infectious pneumonia

TX options for mitral valve stenosis that are not pharmacologic?

Balloon valvuloplasty-catheter Valve repair Mitral valve replacement

Your patient is a 45-year-old female who is allergic to sesame seeds, which she accidentally ingested when she ate a deli sandwich. She is having difficulty breathing, and she has hives, watery eyes, a weak pulse of 120 per minute, and swelling of the face and tongue. Which of the following is the BEST course of immediate action? Transport immediately. Contact medical control for orders to administer the patient's epinephrine autoinjector. Contact dispatch to see where the closest ALS unit is. Insert an oropharyngeal airway.

Contact medical control for orders to administer the patient's epinephrine autoinjector.

What is AAA

Dilation of the aorta greater than 30 mm in diameter; Greater than 55 mg, then it is considered large and requires urgent treatment. The aorta wall is weakened and thinning of the media and adventitia occurs due to the loss of vascular smooth muscle.

Diagnostics for pt with suspecting Cardiac Tamponade?

Echocardiogram

A nurse observes an ECG from a patient with heart palpitations. They are experiencing heart palpitations. The ECG confirms that the patient is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment

What medications do you deliver first for anaphylaxis? ;

Epinephrine;

What are the finding/ S&S if the pt is in DIC? What is it?

Hemorrhage and Abnormal coagulation

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) i. A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking

Which of the following is NOT an indication that epinephrine is helping the anaphylaxis patient's condition? Increased blood pressure Increased heart rate Increased dyspnea Both B and C

Increased dyspnea

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Irregular pulsations :

While caring for a patient who has acute pericarditis, the nurse suspects the development of cardiac tamponade based on which assessment finding? a. A pulsus paradoxus of 8 mmHg b. Jugular vein distention c. Increased systolic blood pressure with widening pulse pressure d. Hiccups, coughs and hoarseness

Jugular vein distention

Which of the following changes commonly occurs in the cardiovascular system during anaphylaxis? Low blood pressure due to vasodilation High blood pressure due to tachycardia High blood pressure due to vasoconstriction Low blood pressure due to bradycardia

Low blood pressure due to vasodilation

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort

Lower back discomfort

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

Much greater amplitude than the usual QRS complexes

What can you find on an assessment for a pt who has pericardial effusion? And what would you do for them?

Muffled Heart sounds, hypotension, sinus tachycardia Prepare for Pericardiocentesis We want to avoid Cardiac tamponade (CT)

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

Nausea Urticaria Stridor

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

Necrosis Think STEMI a blockage is causing heart muscle to die

A nurse is interpreting an EKG strip for a client who has (rhythm) which of the following cardiac components should the nurse identify as the role of something in the actual cardiac rhythm ( like Whats the role of the P wave, QRS interval, T wave) What do they signify?

P wave: depolarization of atria, atrial contraction QRS: depolarization of ventricles, ventricle contraction T wave: repolarization of ventricles, ventricle relaxation

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? Pacemaker spikes after each QRS complex Pacemaker spikes before each P wave Pacemaker spikes before each QRS complex Pacemaker spikes with each T wave

Pacemaker spikes before each QRS complex

A patient with severe pericarditis has developed a large pericardial effusion. The patient is symptomatic. The physician orders what type of procedure to help treat this condition?* A. Pericardiectomy B. Heart catheterization C. Thoracotomy D. Pericardiocentesis

Pericardiocentesis

A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply) A. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Prepare for intubation and mechanical ventilation. d. Administer large volumes of lactated Ringers solution. e. Administer high-flow oxygen (100%) by non-rebreather mask

Prepare to administer atropine IV. Obtain baseline body temperature. Prepare for intubation and mechanical ventilation. Administer high-flow oxygen (100%) by non-rebreather mask

Would you feel a PAC? (premature atrial contraction)

Probably not as much as PVC

What should a normal sinus rhythm look like?

Regular every P has a QRS rate 60-100 bpm PR interval: 0.12-0.20 sec QRS complex is < 0.12 or equal to 0.12 QT interval: < 0.45 seconds ST segment : 0.08 to 0.12, not elevated or inversions

A fib

Regular * Rate: Less than 100 "controlled," greater than 100 "uncontrolled" or "RVR" * * P wave:unable to define * PRI: Unable to define QRS: less than 0.12

A flutter

Regular or irregular Rate: ventricular rate varies, atrial rate estimated 250-350 bpm P wave: "SAWTOOTH" , may have set ratios to QRS or be variable PRI: Unable to define QRS: less than 0.12

V fib:

Regularity: chaos Rate: NA P wave: NA PRI: NA QRS: NA

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

Report of sudden, severe back pain

RF for Triple AAA: (select all that apply)

SMOKING , male sex, older than 65, and family history

Who is at high risk for developing neurogenic shock?

Spinal cord trauma / Spinal injury T6 and above RF: Spinal cord injury, Guillain-Barré syndrome and spinal anesthesia

Neurogenic shock -

Spinal injury, trauma, T6 and above occurs due to autonomic dysregulation caused by a primary and secondary spinal cord injury above the level of T6, often associated with trauma to the cervical or thoracic vertebrae. (spinal cord trauma, Guillain-Barre Syndrome)

If a patient was having a myocardial infarction, not an allergic reaction, and received an epinephrine auto-injection, which of the following would most likely occur? Bradycardia Stronger and faster heartbeat No reaction if administered inadvertently Relief of shortness of breath

Stronger and faster heartbeat

A nurse is administering subcutaneous epinephrine for a client who is experiencing anaphylaxis. The nurse should monitor the client for which of the following adverse effects? A. Hypotension B. Hyperthermia C. Hypoglycemia D. Tachycardia

Tachycardia

A nurse is caring for a client who has a demand pacemakerinserted with a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes B. Premature ventricular complexes at 12/min C. Telemetry monitoring showing pacing spikes with no QRS complexes D. Hiccups

Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

Temperature of 39.1°C (102.4°F)

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave is before the QRS complex The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave.

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

atropine

Obstructive shock -

attention pneumothroax, pulmonary embolism, cardiac mass, choking (think blocking airway),

Anaphylactic shock -

hypersensitivity reaction mediated by IgE (foods, latex, medications, insect bites)

Late/rupture signs of AAA :

i. Shock ii. Intense abdominal pain iii. Back pain iv. Noticeable abdominal distension v. Umbilical ecchymosis (Cullen's sign) vi. Flank ecchymosis (Turner's sign)

hypovolemic shock

loss of fluid or blood, occurs when intravascular volume is decreased, resulting in poor CO. Volume loss may be a result of blood loss or extracellular fluid loss. Shock occurs when a client experiences a loss of 25% to 30% of their circulating volume. RF: Dehydration, Injury, Internal bleeding, Chronic medical con.- CKD, DM, Heart Disease, blood thinner use Body goes into acidosis from the release of Lactic acid

V tach

regular Rate: greater than 100 P wave: NA PRI: NA QRS: greater than 0.12

SVT

regular Rate: typically greater than 150 P wave: hidden by T wave PRI: Unable to define QRS: Less than 0.12

sinus tachycardia

regular * Rate: greater than 100 * P wave: upright, uniform, regular PRI: 0.12-0.20 QRS: less than 0.12

Sinus Bradycardia

regular * Rate: less than 60 * P wave: upright, uniform, regular PRI: 0.12-0.20 QRS: less than 0.12

PT teaching for AAA

should be instructed to STOP SMOKING , implement an exercise regime, and change to a low-fat, low-sodium diet. Clients with a diagnosed intact AAA that is being monitored should be taught the importance of maintaining blood pressure within the expected reference range and ceasing to smoke. Reduce stress

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

tachycardia