unit 2 AN

Cardiac Tamponade s/s

JVD, widened pulse pressure, hypotension (Becks Triad) widened pulse pressure cardiac output low CVP high tachycardia distant heart sounds (muffled) JVD decrease bp

tx for pulmonary edema

M - Morphine D - Diuretics (furosemide) O - Oxygen G - Gases (blood gases)

MAD DOG for tx of pulmonary edema

M- meds (morphine) A-airway D- decrease preload (nitroglycerin IV) D- diuretics: pull excess fluid off O- oxygen G-blood gases sit them up vasodilators morphine- causes vasodilation resulting in decrease bp, reduce workload of heart minimize stress nitro= improve heart function

tx and meds of aortic aneurysm

Maintain blood pressure at normal level. Prevent sudden elevations caused by exertion. Prevent stress, coughing, constipation Surgical repair can live w it blood thinners maintain warm environment (prevent vasoconstriction) meds: antihypertensives vasodilators beta blocker lisinopril antianxiety to control stress stool softners

CABG (Coronary Artery Bypass Graft)

Open heart surgery involving arterial bypass using a transplanted vein to improve blood flow

compensatory stage of shock

SNS causes vasoconstriction, increased HR, increased heart contractility -This maintains BP, CO Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel sounds, decreased urine output Perfusion of tissues is inadequate Acidosis occurs from anaerobic metabolism Respiratory rate increases due to acidosis, may cause compensatory respiratory alkalosis. Confusion may occur.

s/s for MI (including labs)

SOA chest pain (nitro won't help) GI diaphoretic pale arm or back discomfort neck of jaw discomfort lightheaded n/v epigastric pain elevated troponin EKG (within 10 min) CK-MB (not as specific to heart) Ptt and PT D-DIMER (clotting factors) electrolytes

if a pt is having MI what can we see on and EKG

ST elevation or depression

how often and when to draw troponin

STAT hr 2 hr 6 (Serial troponins- look for trend in elevation)

S&S of the progressive stage of shock

Symptoms are worse: Delirium Sense of impending doom Increased thirst Confusion Rapid, weak pulse Low BP Pallor or cyanosis of extremities Cool moist skin; may have anasarca pulmonary edema crackles MAP decrease hypotension oliguria dysrhythmias 5 to 20% decrease in O 2 sat Metabolic Acidosis, rising lactic acid, and hyperkalemia

Effects of Nitroglycerin

Vasodilator- Reduce BP & preload, Reduce O2 demand of heart cause h/a (take aspirin)

A client presents to the ER stating they vomited a "large" amount of bright red blood. Which should the nurse implement first? A Start an IV line with 18-gauge needle B Have the UAP take the client's vitals C Ask the client to provide a stool specimen for blood D Send the client to radiology for a CT of the abdome

a

pulmonary edema

accumulation of fluid in the lungs

complications from chemo/radiation

alopecia wt loss nausea (ondansetron, Phenergan IV-sleepy, magus, diphenhydramine) burns from radiation

symptoms of leukemia

anemia infection bleeding

Complications of MI

arrhythmias especially sudden deat VT or VF -cardiogenic shock -pericarditis/tamponade -chronic CHF -ventricular rupture -hypoxia -cardiac tamponade -pulmonary edema -blood clots -reoccurrence

nursing assessment of aneurysm

auscultate for bruit over abdominal aorta BUN and creatine monitor assess for pulsation in lower abdomen observe for signs of rupture include hypovolemic and cardiac shock w sudden abdominal pain assess all peripheral pulses and vital signs observe for occlusion of the graft change in pulse, severe pain

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care? A Check the IV site for bleeding every 8 hours. B Limit intramuscular injections C Obtain a rectal temperature every 8 hours D Check the client for proteinuria

b

An elderly female client with vertebral fractures who has been self-medicating with ibuprofen presents to the ER. The client complains of abdominal pain, is pale and clammy, and has a pulse of 110 and BP of 92/60. Which type of shock should the nurse suspect? A Cardiogenic B Hypovolemic C Neurogenic D Septic

b

The healthcare provider is teaching a group of senior citizens about risk factors for heart failure. Which of these factors will the healthcare provider include in the teaching? Select all that apply. A Increased high density lipoproteins (HDL) B Hypertension C Obesity D Sleep Apnea E High sodium intake F Atrial fibrillation

bcdef Atrial fibrillation High sodium intake Sleep Apnea Obesity Hypertension Explanation: A sustained increase in cardiac workload can cause heart failure. Untreated hypertension increases peripheral vascular resistance and cardiac workload. High sodium intake increases circulating volume and preload. Sleep apnea is associated with diastolic dysfunction. Obesity increases cardiac workload.

myeloma causes

bone marrow problem

A nurse is attending a cardiopulmonary resuscitation (CPR) class. When performing CPR for an adult, the nurse should evaluate circulation by palpating which of the following pulses? A Radial B Femoral C Carotid D Brachial

c

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? A Pacemaker spikes after each QRS complex B Pacemaker spikes before each P wave C Pacemaker spikes before each QRS complex D Pacemaker spikes with each T wave

c

The nurse is teaching a client with a new implantable cardioverter defibrillator (ICD) who is preparing to discharge. What instruction does the nurse emphasize to the patient? A Rest for several hours after an ICD shock before resuming activities B Have family members step away during ICD shock for safety C Expect that the shock may feel like a thud or a painful kick in the chest D Report any pulse rate higher than what is set on the pacemaker

c

The nurse measures the blood pressure of a client being seen for the first time. The blood pressure is 156/94. The nurse's next priority is to collect data about which risk factor for hypertension? A Ethnic Group B Protein intake C Excess weight D Full history

c

The oncoming nurse just received the shift change report. Which client should the nurse assess first? A A client with coronary artery disease who has a BP of 160/90 B A client diagnosed with pneumonia who has a pulse oximeter reading of 90% C A client diagnosed with a deep vein thrombosis who is complaining of palpitations and dizziness D The client diagnosed with ulcerative colitis who has bloody diarrhea

c

what is shock

condition in which tissue perfusion is inadequate to dleiver oxygen, nutrients to support vital organs, cellular function

antidote for digoxin

digoxin immune FAB

S/S of pulmonary edema

dyspnea, pale/sweaty, hypertension, tachycardia, crackles/wheezing, low SPO2

s/s of irreversible stage of shock

extreme hypotension anuria jaundice lactic acidosis respiratory failure hypoactive/absent bowel sounds

Nursing care post CABG

foley (accurate I&O) pulses checked distally o2 continuous tele central line NG or OG tube bear hugger transferred to a diff unit

nursing care of shock pt

foley care oral care peri care tele monitor labs/vs CNS assessment (5 P's) closely monitor IV drips suction and emergency equipment at bedside frequent turning SCD's heparin or lovenox? central line care med titration nutritional care mental health support monitor hemodynamic status recognize early s/s and prevent use only vasoactive meds if fluids do not increase map

symptoms lymphoma

hodgkins: painless lymph node enlargement (localized) fever sweats wt loss (survival rate good)

RF for MI

hyperlipidemia hypertension obesity diabetes smoking unhealthy diet

pt w lymphoma, myeloma, and leukemia are at increased risk of

infection bleeding weakness, fatigue impaired nutrition fluid and electrolyte imbalance emotional support adv directives

causes of leukemia

leukocyte/platelet problem

survival rate of myeloma

low survival rate (2-5 yrs) no cure

causes of lymphoma

lymph problems

management of aneurysm

med management: -monitor bp -adm antihypertensives surgical: -monitor arterial pressure -EKG -hemodynamics -monitor circulation -HOB below 45 to prevent flexion of graft -monitor for occlusion/ ruptures

mnemonic letter for MI

morphine/fentanyl oxygen nitrates (sublingual, IV drip) aspirin reperfusion (thrombolysis or primary PCI) clopidogrel (prasugrel) heparin beta blocker anticoagulant (aspirin or clopidogrel) statin inhibitors of angiotensin II (ACE or A2R) correction of risk factors

Bex Triad (tamponade/pericarditis assessment)

muffled heart sounds JVD hypotension

risk factors for cardiogenic shock

myocardial infarction cardiomyopathy valvular damage cardiac tamponade dysrhythmias

steps to perform MONA

nitro o2 aspirin morphine/fentanyl (decrease pain & o2 uptake)

survival rate for lymphoma

non hodgkins cells; spread is unpredictable (survival rate variable)

left sided heart failure s/s

orthopnea S3 heart sound crackles tachycardia blood tinged sputum wheezes/soa confusion/altered loc tripod position paroxysmal nocturnal dyspnea elevated pulmonary capillary wedge pressure cough (dry hacky early and wet late) tachypnea fatigue cyanosis

symptoms of myeloma

pain hypercalcemia fractures

how to fix tamponade

pericardial window and chest tube drain at bedside

a pt is admitted w severe chest pain and has been diagnosed w a dissecting abdominal aortic aneurysm. what are clinical manifestations

pulsating abdominal mass low back pain SOA bp changes palpitations

Tx of right sided hf

reduced Na, digitalis, diuretics

Process of CABG

reroute blood flow using veins from leg or arm harvest vein (leg or arm) put vein above occlusion site and below to reroute

nursing education at home post cabg

splinting/pillow hugging walking follow up/cardiac rehab s/s inifection clean wounds med compliance dietary changes financial burden diabetic teaching transportation resources

why not to hot or to cold foods? what can u give these pt

stomatitis lidocaine after meals to help w pain

what are potential complications that can occur w sustained elevated bp

stroke or TIA coronary artery disease w angina heart attack left ventricular hypertrophy

survival rate of leukemia

survival rate dependent on type and tx reaction

complications from hf

tamponade pulmonary edema cardiogenic shock

nursing care for hypertensive emergent/urgent pt

tele bed rest decrease stimuli decrease caffeine, sodium monitor for signs of organ damage (kidney damage, labs, urine output) I&O (foley if more severe)

UNLOAD FAST for CHF

upright position nitrates lasix oxygen ace inhibitors digoxin fluids (decrease) afterload (decrease) sodium restriction test (digoxin level, ABGs, K+ level)

S/S of cardiogenic shock

↑ HR ↑ RR ↓ BP ↓ urinary output restless diaphoretic cool/clammy skin change in mental status dyspnea narrow pulse pressure dusky skin color (poor perfusion) pulmonary congestion increased preload anxiety and delirium

Tx of cardiac tamponade

- Thoracotomy (pericardial window to put in chest tube to drain) - mediastinal drain - Pericardiocentesis can be done to provide immediate decompression sit pt up oxygen call dr morphine meds (dopamine and dobutamine)

Irreversible stage of shock

-At this point, organ damage so severe that patient does not respond to treatment, cannot survive -BP remains low -Renal, liver function fail -Anaerobic metabolism worsens acidosis -Multiple organ dysfunction progresses to complete organ failure -Judgment that shock is irreversible only made in retrospect

progressive stage of shock

-Mechanisms that regulate BP can no longer compensate, BP and MAP decrease -All organs suffer from hypoperfusion -Vasoconstriction continues further compromising cellular perfusion -Mental status further deteriorates from decreased cerebral perfusion, hypoxia -Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia, carbon dioxide levels increase, alveoli collapse, pulmonary edema occurs -Inadequate perfusion of heart leads to dysrhythmias, ischemia -As MAP falls below 70, GFR cannot be maintained -Acute renal failure may occur -Liver function, GI function, hematological function all affected -DIC (Disseminated Intravascular Coagulation) may occur as cause or complication of shock

Right sided heart failure s/s

-Peripheral and dependent edema -Jugular venous distension -Increased abdominal girth due to venous congestion of the gastrointestinal tract -hepatomegaly, -splenomegaly -ascites. -Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation -Hepatomegaly due to hepatic venous congestion -SOA

tx for shock

-Treat the cause -Remain calm -Keep patient calm -Maintain normal temperatures (warm) -Keep flat -Elevate legs ~12 inches -Oral fluids (long evac, good LOR--> A+O x 3 or 4) -O2 -Monitor closely -vasopressors -fluids (depend on type of shock) -hemodynamic monitoring -mechanical assistive devices -pain control -nutritional support (TPN, G tube if bowel is working) -norepi and dobutamine fluid replacement: -crystalloid, colloid solution -blood administration

Digoxin therapeutic range

0.5-2

what size IV if pt has signs of MI

18g; 2 if possible

A cardiac surgery patient is being ambulated when another staff member tells them the client has developed SVT with a rate of 160bpm. The patient is also very pale and states they don't feel well. In what order will the nurse take these actions? No spaces or commas. 1.Call the client's physician 2.Have the client sit down 3.Check the client's blood pressure 4.Administer oxygen by nasal cannula

2431

how quickly to get to PCI (door to balloon time) (cath lab)

60 minutes

troponin INT level

< 0.04

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a BP of 80/60. The nurse should take which of the following actions first? A Prepare for transcutaneous pacing B Prepare for defibrillate the client C Administer an IV lidocaine infusion D Schedule the operating room for insertion of a permanent pacemaker

A

life threatening complications of aortic dissection (AORTIC)

A- aortic insufficiency O-occlusion of coronary artery R-rupture T-tamponade I-ischemic of viscera C-CVA

Tx of left sided heart failure

ACE inhibitors, diuretics for sx

A client who had CABG 24 hours ago has a urine output averaging 15mL/hr for 2 hours. The client received a single bolus of 500 mL of IV fluid. The urine output for the next hour was 25 mL. The doctor ordered lab and the results were as follows: BUN 45 mg/dL and serum creatinine is 2.2 mg/dL. How would you interpret these results? A Hypervolemia B Acute renal failure C Urinary tract infection D Glomerulonephritis

B

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? A Attach defibrillator pads to the client B Check for a carotid pulse C Begin chest compressions D Deliver two breaths

B

Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? A The client can identify risk factors of an MI B The client can perform self-care activities C The client has severe chest pain D The client agrees to cardiac rehab

B

what should you do before adm nitro

BP

hypertensive urgency

BP is very high but no evidence of immediate or progressive target organ damage oral meds are sufficient meds: -beta blockers -diuretics

hypertensive emergency

Blood pressure >180/120 mm Hg and must be lowered immediately to prevent damage to target organs -inpatient situation, ICU/step down -iv meds needed: nitro or nicardipine

RF to receive a CABG

CAD Ca+ heart score obesity hyperlipidemia HTN uncontrolled smoking increased age

what are the stages of shock

Compensatory -body is still attempting to work -no massive changes or symptoms (tachycardia, slow drop in bp, tachypnea, loc changes- restlessness, Progressive Irreversible

A nurse is providing discharge teaching to a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective? A "I will read food labels and limit my sodium to 4gm per day." B "I should use naproxen to manage discomfort." C "I will take my diuretic before sleep and drink fluids during the day." D "I plan to slow down if I am tired the day after exercising."

Correct Answer: "I plan to slow down if I am tired the day after exercising." Explanation: Clients with heart disease should avoid use of NSAIDs because it can cause sodium retention and increased risk for MI. Clients who have chest pain or dyspnea/fatigue after exercise are probably going to fast/hard and should slow down activity.

You receive orders for your client with a myocardial infarction to start an IV Heparin drip at 18 units/kg/hr and to administer a loading bolus dose of 30 units/kg IV before initiation of the drip. You're supplied with the heparin bag in the picture. The patient weighs 172 lbs. What is the flow rate you will set the IV pump at (mL/hr), and how many units will be administered for the IV bolus? Round answers to the nearest tenth. (bag; 25,000/500mL)

Correct Answer: 28.2 mL/hour and 2345.5 unit bolus Explanation: 28.2 mL/hour and 2345.5 unit bolus

In a patient's record, the nurse notes frequent episodes of bradycardia and hypotension related to unintended vagal stimulation. Which instructions for this patient's care does the nurse relay to the unlicensed assistive personal (UAP)? A Avoid raising the patient's arms above the head during hygiene B Ambulate the patient slowly and stop frequently for brief rest C Monitor the heart rate and rhythm if the patient is vomiting D Generously lubricate a rectal thermometer probe and insert very cautiously

Correct Answer: Ambulate the patient slowly and stop frequently for brief rest

A nurse is monitoring central venous pressure. What statement is correct regarding central venous pressure? A Central venous pressure is not important in hemodynamic monitoring B A decreasing trend in central venous pressure may indicate right heart failure C It is better to look at current numbers for monitoring rather than trends D An increasing trend in central venous pressure can indicate fluid build-up

Correct Answer: An increasing trend in central venous pressure can indicate fluid build-up Explanation: CVP is central venous pressure. How much pressure is in the central venous system. Low number-hypovolemia, high number-hypervolemia.

A nurse is caring for a client who had CABG with the radial artery used as a graft. The nurse performs which assessment specific to this patient? A Check the blood pressure hourly on the unaffected arm B Check the fingertips, hands, and arms for sensation and mobility every shift C Assess the color, temperature, pulses and capillary refill on the affected extremity hourly D It is expected to have edema, bleeding, and swelling at the donor site

Correct Answer: Assess the color, temperature, pulses and capillary refill on the affected extremity hourly

A nurse is caring for a client who has valvular heart disease and is at risk for developing left -sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A Anorexia B Weight loss C Breathlessness D Distended abdomen

Correct Answer: Breathlessness Explanation: Left=lungs, weight gain with edema is more indicative of right sided heart failure (right=body)

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values? A Absolute Neutrophil Count (ANC) B Calcium C Platelets D White Blood Cells (WBC)

Correct Answer: Calcium Explanation: Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell. Healthy plasma cells help you fight infections by making antibodies that recognize and attack germs. In multiple myeloma, cancerous plasma cells accumulate in the bone marrow and crowd out healthy blood cells. Increased calcium can lead to kidney problems. Bone pain and fractures are issues.

The nurse has completed an assessment on a client with a decreased cardiac output. Which finding should receive the highest priority? A BP 110/62, atrial fibrillation with HR 82, and bilateral basilar crackles B Confusion, urine output 15 mL over past 2 hours, orthopnea C SpO2 92% on 2L NC, respirations are 20, 1+ edema to lower extremities D Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise

Correct Answer: Confusion, urine output 15 mL over past 2 hours, orthopnea Explanation: Count how many issues each patient has. B is much worse than the rest.

The nurse is assessing a client who is reporting dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? A Asthma B Aortic valve regurgitation C Heart failure D Aortic stenosis

Correct Answer: Heart failure Explanation: A-no this is cough, dyspnea, and wheezing B-Dyspnea, orthopnea and nocturnal angina can occur C-yes! Tachycardia is early sign of HF. Other signs are difficulty breathing and weak pulses (poor output) D-Dyspnea, angina, syncope with fatigue and might have peripheral cyanosis

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? A Hepatomegaly B Dizziness C Crackles in the lungs D Dry, hacking cough

Correct Answer: Hepatomegaly Explanation: Right sided heart failure the fluid backs up to the body, including the liver (hepatomegaly)

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A Increased heart rate B Increased urine output C Decreased blood pressure D Decreased blood glucose

Correct Answer: Increased urine output Explanation: Tachycardia is an adverse effect. Dobutamine is given to clients with heart failure to improve their hemodynamic status. The nurse should identify an increase in client's urine output as an indication that the medication is effective.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A Attach the leads for a 12-lead ECG B Obtain a blood sample C Initiate oxygen therapy D Insert the IV catheter

Correct Answer: Initiate oxygen therapy Explanation: The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A Sudden lethargy B Muffled heart sounds C Flattened neck veins D Bradycardia

Correct Answer: Muffled heart sounds Explanation: A-will be restless B-RIGHT! fluid around heart decreases sound transmission C-JVD will occur due to back up of fluid (heart can't fill when compressed) D-tachycardia will occur due to heart working harder and trying to pump blood

A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings? A Acute pericarditis B Deep vein thrombosis (DVT) C Peripheral artery disease (PAD) D Right ventricular heart failure

Correct Answer: Right ventricular heart failure Explanation: Pulmonary valve dysfunction decreases blood flow to the lungs. Pulmonary valve dysfunction increases the workload of the right ventricle. A sign of right ventricular (right-sided heart failure) failure is peripheral edema.

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A Sit the client up and apply oxygen B Place the client in high-Fowler's with legs elevated C Give the client a sublingual nitroglycerin and send to the cath lab D Reassure the client that everything is going to be instruct on deep breathing

Correct Answer: Sit the client up and apply oxygen Explanation: A client with pulmonary edema is critically ill and is hypoxic. First action is airway.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A The client cannot travel by air due to security screening B The client should place their cell phone on the opposite side of the ICD C The client should always avoid use of small electrical devices D The client can carry their ICD in a small pocket

Correct Answer: The client should place their cell phone on the opposite side of the ICD Explanation: The client should keep his cellular phone on the side opposite the ICD, as close proximity could interfere with the ICD's function.

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? Select all that apply. A A client who has metabolic alkalosis B A client who has serum potassium level of 4.3 mEq/L C A client who has an SaO2 of 91% D A client who has COPD E A client who underwent stent placement in a coronary artery

Correct Answers A client who has metabolic alkalosis A client who has COPD A client who underwent stent placement in a coronary artery Explanation: Think about what things could cause electrolyte imbalances or irritation to the heart.

A patient has had synchronized cardioversion for unstable ventricular tachycardia. Which intervention does the nurse include in this client's care after the procedure? Select all that apply. A Administer therapeutic hypothermia B Assess vital signs and level of consciousness C Administer antidysrhythmic drug therapy D Monitor for dysrhythmias E Assess for chest burns from electrodes

Correct Answers Assess vital signs and level of consciousness Administer antidysrhythmic drug therapy Monitor for dysrhythmias Assess for chest burns from electrodes

A patient has a permanent pacemaker surgically implanted. What are the nursing responsibilities for the care of this client related to the surgery? Select all that apply. A Administer short acting sedatives B Assess the implantation site for bleeding, redness, swelling, tenderness, or infection C Teach about and monitor for the initial activity restrictions D Observe for over-stimulation of the chest wall which could lead to pneumothorax E Monitor the ECG rhythm to check that the pacemaker is working correctly

Correct Answers B) Assess the implantation site for bleeding, redness, swelling, tenderness, or infection C) Teach about and monitor for the initial activity restrictions E) Monitor the ECG rhythm to check that the pacemaker is working correctly

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a central venous pressure (CVP) of 10. Which of the following should the nurse expect. Select all the apply. A Bilateral crackles in the lungs B Jugular vein distention C Dry mucous membranes D Hepatomegaly E Poor skin turgor

Correct Answers Bilateral crackles in the lungs Jugular vein distention Hepatomegaly Explanation: Normal CVP is 2-6. If this number is high then the patient has hypervolemia. What are the signs of hypervolemia.

A nurse is caring for a client following a coronary artery bypass graft. Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? Select all that apply A Place the client in high-fowler's position B Level the transducer to the phlebostatic axis C Zero the system D Observe for trends in readings E Compare readings to the physical assesment

Correct Answers Level the transducer to the phlebostatic axis Zero the system Observe for trends in readings Compare readings to the physical assesment Explanation: You must have the transducer at the right level, you also must zero the system, you need to look at trends in readings. One random reading doesn't mean that the patient is bad, compare that to their assessment, maybe they system isn't working.

The nurse is assessing a client who has had a myocardial infarction. The client is at risk for cardiogenic shock. Which of the following assessment findings would indicate early cardiogenic shock? Select all that apply. A warm, flushed skin B PaO2 of 80 C Urine output of 30 mL an hour D Respiratory rate of 26 E Blood pressure of 70/40 after administering dopamine

Correct Answers Respiratory rate of 26 Urine output of 30 mL an hour PaO2 of 80

A nurse is caring for a client who is post-angioplasty. Which of the following findings should the nurse report to the provider immediately? Select all that apply. A Bigeminal premature ventricular complexes (PVCs) on the cardiac monitor B 1+ pedal pulse in unaffected extremity C Urine output approximately 20mL/hr D Increased pain/discomfort at the insertion site E Visual disturbances

Correct Answers: Bigeminal premature ventricular complexes (PVCs) on the cardiac monitor Urine output approximately 20mL/hr Increased pain/discomfort at the insertion site Visual disturbances

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. The CVP was 2. Which of the following interpretations of a low CVP pressure should the nurse make? A Fluid overload B left ventricular failure C Intracardiac shunt D Hypovolemia

D

A nurse is orientating a newly licensed nurse on the care of a client who is receiving invasive hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? A "Air should be instilled into the monitoring system." B "The client should be in the prone position." C "The transducer should be level with the 2nd intercostal space." D "A chest x-ray is needed to verify placement."

D

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? A Draw blood for laboratory studies B Insert a Foley catheter C Weigh the client D Assess the client's respiratory status

D

The nurse is caring for a client with leukemia who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is most important to immediately report which sign if it occurs? A Fatigue B Weakness C Tiredness D Backache

D

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first? A Administer atropine 0.5mg IVP B Auscultate for abnormal heart sounds C Prepare for transcutaneous pacing D Take the client's blood pressure

D

Tx of cardiogenic shock

Dobutamine dopamine IV access art line (invasive bp) oxygen therapeutic environment I&O daily wt telemetry pulm artery catheter (more accurate cardiac output monitoring) hemodynamic monitoring foley morphine nitroglycerin (in low doses, decreases preloads, high doses can decrease afterload. this action can decrease workload)

signs of pulmonary edema

Dyspnea pale and sweaty tachycardia hypertension respirations are rapid and labored low blood ox crackles and wheezes cough up pink frothy sputum

Digoxin toxicity s/s

GI effects (anorexia, n/v, abdominal pain), CNS effects (fatigue, weakness, diplopia, blurred vision, yellow-green or white halos around objects)

complications of CABG

Infection (pneumonia) Acute renal failure Stroke GI bleed Atelectasis Pleural effusion Cardiac tamponade/pericarditis Poor healing A fib or a flutter/dysrhythmias hypothermia hypo/hyper volemic heart failure electrolyte imbalances (mg or ka) neuro deficit (stroke) compartment syndrome graft occlusion