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The nurse is caring for a patient with acute inferior wall MI, post-coronary artery stent deployment, For optimal care of the patient, the nurse should: ANSWERY ¥ Continuously monitor the patient in lead II It is best practice to monitor the patient status post PCI with stent, in the lead that was most abnormal during the acute occlusion. The ECG demonstrates ST clevation in leads TI, HI and aVF. The nurse needs to monitor the patient closely for which of the following? ANSWER¥ ¥ Complication likely to occur after an acute inferior wall MI include bradycardia secondary to ischemia to the SA and/or AY node, and papillary muscle rupture or dysfunction due to the anatomical distance between the RCA and the papillary muscle. Which of the following hemodynamic profiles would benefit from the aggressive fluid administration, pressers and antibiotics therapy? a. RAP: Imm Ig; PAOP: 4 mmIIg; SVR: 1800 dynes/sec; CO: 2L/min b. RAP: 5; PAOP: 7; SVR: 400; CO; 8L ANSWERV VY B. the hemodynamic profile of RAP 5, PAOP 7, SVR 400 is typical of septic shock, and choice B would be the best approach. Which of the following is indicative of a mixed acid-base disorder? A. pH 7.18; PaCO2 25; PaO2 64; HCO3 11 B. pH 7.33; PaCO2 29: PaO2 72; HCO3 15 ANSWERV ¥ The decrease in PaCO2 is evidence of respiratory alkalosis and the decreased HCO3 is evidenced of a metabolic acidosis. The pt with severe sepsis or septic shock may present with this mixed acid-base disorder. The patient with a temporary pacemaker develops pacemaker malfunction. The oriented is instructed to reposition the patient to try and correct the problem. The cardiac monitor most likely demonstrates? ANSWERV ¥ Failure to capture (pacemaker without a QRS) may be corrected by repositioning the patient to the side. ‘The patient with diastolic heart develops SVT, heart rate 220/min. The most dangerous hemodynamic effect is a decrease ins ANSWERV ¥ coronary artery perfusion. Diastolic heart failure results in a problem with left ventricular FILLING secondary to ventricular thickening, and contractility and ejection are maintained in diastolic failure. The rapid heart rate will decrease filling time, worsen left ventricular filling and because coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. The patient is receiving heparin infusion for the treatment of pulmonary embolism. There has been a 60% decrease in the platelet count and no clinical change. Which of the following is indicated? ANSWERV ¥ Discontinue heparin and being argatroban. The patient most likely has HIT. Exposure to heparin needs to discontinued and a direct thrombin inhibitor started for continued anticoagulation. The patient with oat cell carcinoma has the following clinical findings: low urine output, low scrum osmolality, hyponatremia, and clevated urine sodium. The nurse anticipates which of the following as part of the treatment plan? ANSWER ¥V Phenytoin (Dilantin), 3% saline. B. Fever C. Severe sepsis ANSWERV V Fever Fever increases metabolic rate and consumption, which may lead to a drop in mixed venous oxygen saturation. ‘The nurse needs to assess adequacy of the tubing/catheter system for the arterial line. Which of the following interventions will best assess this? ANS WERV V Perform a square wave test The patient requires fluid resuscitation and 8 units of PRBC's status post traumatic injury. Which of the following interventions is most appropriate? ANSWERV V Warm blood products and crystalloids Warming fluids and blood needed for traumatic injury will prevent hypothermia and its related adverse effects. Which of the following therapies should be avoided for the patient with cardiogenic shock? ANSWERYV ¥ high dose vasopressors Vasopressors increase left ventricular afler load, which would increase myocardial work of a failing heart. The patient is status post repair of an aneurysm for subarachnoid hemorrhage. Which of the following interventions is indicated to prevent vasospasm? ANSWERV V Nimodipine (Nimotop) is a calcium channel blocker that is started immediately post-op to prevent arterial spasm of the brain. The patient presents with a rigid abdomen, rebound tenderness, and a free air in the peritoncum scen on KUB x-ray. Which of the following should the nurse anticipate? ANSWERV ¥ Powell perforation; provide fluids. prepare for surgery. The clinical signs are those of bowel perforation. Which is the priority treatment for the pt with DKA who presents with hyperglycemia, ketosis, and normal serum potassium? ANSWERV ¥ replace potassium The patient with DKA will have a low pH and metabolic acidosis. In a state of metabolic acidosis, hydrogen ions move into the intracellular space. In exchange, potassium leaves the intracellular space. The movement of K into the extracellular space results in hyperkalemia. Which of the following is a systemic effect of the therapeutic hypothermia during the cooling phase? ANSWERV V Hyperglycemia secondary to insulin resistance. During the cooling phase of clinical hypothermia there is typically insulin resistance. Additionally, during the phase there is vasoconstriction, decreased neutrophil production and during rewarming, rebound hyperkalemia may occur (not during the cooling phase). The patient presented to the ED with a history of palpitations and dyspnea, persisting on and off for one week. The heart monitor shows trail fibrillation with rapid ventricular response, blood pressure 112/70. Treatment will most likely include: ANS WERV V CCB and anticoagulation This type of angina is thought to be due to arterial spasm at the point of coronary artery plaque, not due to plaque rupture. The ST elevation is transient because the spasm is relieved with nitrates; therefore infarction does not occur. The most specific clinical sign for the presence of brain death would include which of the following? ANSWERV ¥ Absent oculocephalic reflex If eyes remain midline or turn to the side of head rotation, it is a sign of cranial nerve VIII damage and possible brain death. The apnea test is positive in the presence of brain death; while coma is present during brain death, most patients with coma do not have brain death. The physician determines the paticnt has ARDS. The patient has developed refractory hypoxemia, bilateral infiltrates, and pulmonary edema on chest x-ray. What findings would be expected? a. increased lung compliance b. PAOP normal or low c. decreased cardiac output ANSWERV V¥ b. The pulmonary edema of ARDS is due to lung capillary leak at normal or even low left heart pressure, unlike cariogenic pulmonary cdema, which results in pulmonary edema at higher than normal left heart pressure. The patient presents one month status post gastric bypass bariatric surgery with vomiting, headache, diplopia, and memory loss. These are clinical signs of which of the following? ANSWERVV Malabsorption The signs and symptoms are those of malabsorption, which results in vitamin deficiency and may occur after bariatric surgery. The remaining choices are not manifested by the signs and symptoms described. Priority treatment for aortic dissection requires which of the following? ANS WERV / Aggressive management of hypertension and emergent surgery. Emergent surgery is essential for survival, and blood pressure control is essential preoperatively. Pain control and transfusion may be indicated, but the remaining therapies are not beneficial. Inferior MI is associated with? ANSWERV V RCA occlusion AV conduction disturbances: 2nd- degree Type 1, 3rd- degree heart block, Sick sinus syndrome, and sinus bradycardia Development of systolic murmur: mitral valve regurgitation secondary to papillary muscle rupture Also associated with RV infarct and posterior MI Right Ventricular Infarct S&S: What to avoid: ANSWERV V JVD at 45 degrees High CVP Hypotension Usually clear lungs Nitro is a preload and afterload reducer. Assess for cyanide toxicity secondary to drug metabolite (Thiocyanate): mental status change (restlessness, lethargy), tachycardia, seizure, anced for increase in dose. Tests to use for PAD? ANSWERV V Ankle-brachial Index - used to access lower extremity perfusion; normal is greater than 1 Doppler ultrasound testing Arteriography Position for PAD patient? ANSWERV ¥ Bed in reverse Trendlenburg Do NOT elevate the affected extremity - will decrease perfusion Meds: Thromolytics, Anticoagulants, ASA, Vasodilators Drugs that cause Prolongation of the QT interval ? ANSWERV V Procainamide, haloperidol, quinidine, amiodarone Electrolyte problems: hypokalemia, hypocalcemia, hypomagnesemia Pacemaker code: ANSWERV ¥ First initial: Paced 2nd initial: Sensed 3rd: inhibited What is contraindicated with Diastolic heart failure? ANSWERV ¥ Positive inotropes Dehydration further worsens filling ‘Tachyarrhythmias decrease filling tume and worsen symptoms Chest x-ray finding in systolic heart fx? ANSWER¥V V may be evidenced by large, dilated heart or by normal heart size on chest film. Causes of Right side heart failure? ANSWERV V Acute RV infarct Pulmonary Embolism Septal defects Pulmonary stcnosis/regurgitation COPD Pulmonary hin Left Ventricular fx Cause of Left sided heart failure? ANSWERV ¥ CAD, ischemia Myocardial infarction Cardiomyopathy Fluid overload Chronic, uncontrolled htn Aortic stenosis/insufficiency Mitral stenosis/insufficiency Cardiac tamponade 3 (worst) If the score is 8 or less, outcome is poor Which is worse, obtunded or stuporous? ANSWERV V Stuporous - pt cannot speak, moan, grimace. Obtunded - can speak, mumble words. Unele Herniation: ANSWERV ¥ Lateral shift, NO initial change in LOC Most often caused by epidural hematoma that occurs in temporal arca, some strokes Central Herniation: ANSWERV J Swelling on both sides, downward displacement of hemispheres Slight change in LOC and then coma First both pupils are small (1-3mm) then parasympathetic innervation on both sides is suppressed and both pupils dilate Treatment of Vasospasm? ANS WERV ¥ Prevent vasospasm by providing CCB - nimodipine (Nimotop) 60mg q 4hrs, for aneurysmal SAH The first sign of an increase in ICP? ANSWERV V LOC since the "higher" centers of the brain show symptoms first and then progress down toward the brain stem. Hypotension in the presence of Elevated ICP? ANSWERV v Can be devastating!!! Higher MAP is better than low MAP Brain death is less 30mmHg s&s of increased ICP? ANSWERV ¥ Altered LOC Restlessness/agitation Headache Pupillary changes When using the fluid-filled system, the level of the transducer should be at the? ANSWERVV External auditory meatus, which is at the level of the foramen of Monro Neuro Waves? ANSWERV V "A" are awful "B" are bad "C" are common In the presence of Elevated ICP: AVOID? ANSWERV ¥ Acidosis - causes vasodilation which increases ICP Alkalosis - causes vasoconstriction which decreases flow to head. giving Nitroprusside would be bad due to patient having renal failure. A patient with an inferior wall MI has sinus bradycardia with a BP 110/70 and HR 52. A nurse should plan to? ANSWERV ¥ Continue to monitor vital signs A patient is at the highest risk of developing aspiration pneumonia? ANSWERY ¥ Pt with endotracheal intubation with nasogastric tube Which of the following physiological changes should a nurse anticipate when caring for a postoperative pt with morbid obesity ? ANSWER V Decreased functional residual capacity Which fluid is the initial treatment for severe DKA? ANSWERV Vv IV fluids 0.9% Which of the following complicating factors is the most crucial in the care of a critically ill patient with CKD? ANSWERV ¥ Volume status, electrolyte imbalance, and vascular access A pt with a diagnosis of small bowel obstruction has a Miller-Abbott tube in place. A nurse's first priority in the management of this tube is to? ANSWERV V Connect the tube to low intermittent suction A pt who is suspected to have developing SIRS, a nurse should monitor for? ANSWERV ¥ WBC of 14,000 and HR 123 Leukocytosis and tachycardia, along with hyper/hypothermia and tachypnea, are the defining criteria for SIRS ABG of early STATUS ASTHMATICUS? ANSWERY ¥ Respiratory Alkalosis Lab values of increased INR, PTT, and FSP. Hgb, platelets, and fibrinogen are decreased. These values indicate what? ANSWERV ¥ DIC The goal of permissive hypothermia is to do what? ANSWERV V decrease the ICP 15 or less. Higher readings exert pressure on the structures of the brain and impede adequate blood flow to the brain. During resuscitation phase of caring for a patient with a liver injury from acute abdominal blunt force trauma, the focus should be to ? ANSWERV ¥ stabilize hemodynamics What lab value is consistent with Rhabdomyolysis? ANSWERV ¥ hyperkalemia and hypocalcemia Is pulmonary fibrosis related to Status Asthmaticus? ANSWERV ¥ PF is generally idiopathic and unrelated to Status Asthmaticus Which of the following alterations in pulmonary status is most likely to occur in a pt with status asthmaticus? ANSWERV V Hyperinflation Which acid-base problem is mostly seen in pts with renal failure? ANSWERV V metabolic acidosis Why do people with liver dz not clot well? ANSWERY V they don't have prothrombin and fibrinogen High levels of ammonia leads to what? ANS WER¥ ¥ hepatic encephalopathy Why do you not want people with liver dz to develop low potassium levels? ANSWERV 4 because of the kidney will hold onto potassium which leads to high ammonia levels. BUN in liver dz? ANSWERV V breakdown of BUN releases ammonia - so make sure patient is not dehydrated because this will lead to high levels of BUN Do you want people with liver dz to have high levels of protein? Why not? Do you want people with liver dz to have an increase in acid? ANSWERV V No - it leads to ammonia which will lead to hepatic encephalopathy No! Metabolic acidosis duc to low BP Do you give Ringers Lactate to someone with Liver dz? ANSWERV ¥V No! It cannot convert to bicarb because of the liver dz - it will convert to lactic acid Which medication do you give to someone with liver dz? ANSWERV ¥ Neomycin - because it does not release ammonia. BUT it leads to Vitamin deficiency How to tell if you have hepatic failure or billiary tract dz? ANSWERV ¥ Bilirubin and albumin are unconjucated until they go to the liver, where they get conjucated and go to the gallbladder. If someone has indirect or unconjucated bilirubin is it hepatic failure or billiary tract dz? ANSWERVV Hepatic failure Opposite would be gallbladder problem Ruptured spleen has what signs? ANSWERV ¥ Kehrs sign - left shoulder pain What does diuretics do to someone with liver dz? ANSWERV V Lowers their potassium Pre renal failure: ANS WERV V kidneys are healthy, but blood is not getting down to the kidneys, so no urinary output. TX: FLUIDS or INOTROPIC DRUGS Renal stage of acute renal failure: ANSWERV V Kidney damage - most common cause is acute tubular necrosis Nephrotoxicity is caused by: ANSWERV V eating heavy metals/Meds/street drugs/ rhabdomyolysis How to tell Pre renal vs Renal? ANSWERV ¥ Pre renal - needs fluids and inotropic drugs - check urinary sodium level: 20 or less is pre renal. Check BUN/Creatinine levels: BUN 20:1 or Bun of 60 and creatinine of 3 is pre renal 
