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A patient with a non-ST-segment-elevation mycocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? -Heparin will prevent the development of new clots in the coronary arteries. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? -Chest pain level 8 on a 10-point scale A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which on e will the nurse arrange to be completed first? -Electocardiogram (ECG) During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates -elevated right atrial pressure Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. during the first hours of administration, the nurse will need to adjust the nitroprusside rate if the patient develops -a systolic BP < 90 mm Hg A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment information as -Paroxysmal nocturnal dyspnea The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient -calls the clinic when the weight increases from 124 to 130 pounds in a week Following an acute myocardial infarction, a perviously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about -angiotensin-converting enzyme (ACE) inhibitors Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure. -B-type natriuretic peptide (BNP) Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most rapid action by the nurse? -Oxygen saturation of 88% the nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is -decreased dyspnea with the head of bed at 30 degrees Which topic will the nurse plan to include in discharge teaching for a patient with systolic hear failure and an ejection fraction of 38%? -Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include -milk, yogurt, and other milk products
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDiuril). Appropriate instructions for the patient include -notify the health care provider about any nausea (NEVER take digoxin if pulse is below 60) A patient who has just been admitted with pulmonary edema is scheduled to receive these medications. Which medication should the nurse question? -carvedilol (Coreg) 3.125 mg A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low- sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first action will be to -assess the patient for clinical manifestations of acute heart failure After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first? -A patient who is cool and clammy, with new-onset confusion and restlessness An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg). which of these assessment findings is most important for the nurse to report to the health care provider? -BP of 88/42 mm Hg A patient who is receiving dobutamine (Dobutrex) fro the treatment of acute decompensated heart failure (ADHF) has the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? -Monitor the patient's BP and heart rate every hour when admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first? -Attach the cardiac monitor TEST 2 To determine whether there is delay in impulse conduction through the atria, the nurse will measure the length of the patient’s -P Wave The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which method will be best to use? -Use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10 P wave not apparent, ventricular rate 162, r-r interval regular, p-r not measurable, QRS wide and distorted, QRS duration 0.18 seconds -Ventricular tachycardia Atropine effective -Increase pt’s heart rate Pace maker for a-fib -stimulates heart beat if it’s too low Pacemaker teaching effective -won’t lift arm on side of the pacemaker Cardioversion
-Masure output hourly Left radial arterial line take action when -left hand is cooler than the right hand Hemodynamic monitoring teaching effective when -positions the zero reference stopcock line level with the phlebo axis Disturbed sensory perception and disturbed sleep pattern -cluster nursing activities and uninterrupted rest periods Not a treatment for cardiogenic shock -administration of blood product Shock, check for perfusion by -LOC, urinary output, and BP Stung by bee, respiratory distress -epinepherine Shock is caused from -impaired tissue perfusion Fluid recussitation with -normal saline Intubated and making sounds -check cuff inflation on ETT Pilot balloon is deflated with ventilator -nothing required for ventilation Peep immediate intervention needed when -BP drops Vent client becomes restless -check O2 sat Suspect distributive shock in -MVA accident with severe head injury Risk for acidosis -increase serum lactic acid Bleeding internally, assess for shock by -asking what their normal HR is Dopamine effective when -increase cardiac output Distributive shock assess -are you normally this swollen Suspect MODS when -creatinite level is high
Ventilator, notify MD if -JVD Nipride effective -skin is warm, dry, and pink MVA client otw -prep for 2 14 gauge IV catheters Vasopressin, notify MD if -pt c/o chest pain Fluid recussitation successful when -UO is 60 mL over one hour Septic shock, 20 mL/ 3 hr UO, pulse 120 -question Lasix TEST 4 ICP 20 and CPP 85 -ICP high and CPP normal Clear nasal drainage -test it for glucose Cerebral tissue swelling -elevate HOB 30 degrees GCS
15 GCS drops to 13 -notify MD of change Seizures need to be treated beacause -Increase metabolic rate and ICP Mannitol or furosemide -decreases ICP and increase UO Decrease ICP -Mannitol Basilar skull fracture -risk for meningitis ICP through intracatheter -aseptic technique to prevent infection When increase ICP -monitor fluid and electrolytes Increase ICP -bradycardia
-Vasopressin infusion, balloon tamponade, ligation, shunting Hepatitis refer for IG injection -caregiver who lives in household Jaundice, liver function -Do you take any OTC drugs Gullian Barre -immune system destroys myelin sheath Clinical manifestations of GB -progressive ascending weakness and parathesia GB -take things slowly for several months after leaving the hospital Bell’s palsy and herpes -call MD if pain of herpes lesion occurs near the ear Puncture wound, tetanus booster 7 year ago -tetanus booster Trigeminal neuralgia -controllable facial twitching Peripheral nerve repair postop priority -assess skin surrounding cast Trigeminal neuralgia surgery -a small artery compressing the nerve will be relocated Cirrhosis and vomiting worry about -bleeding esophageal varices Mild liver disease, to assess for ascites -palpate abdomen for fluid wave Asterixis -extend your arm, flex wrist up, extend fingers Cirrhosis -Increase serum ammonia level Decreased fecal urobilogen concentration -clay colored stools Hepatitis A -May have been exposed when we ate shrimp last week Sensory -discriminate between touch and pinprick stimuli Halo traction -keep a wrench taped to halo incase CPR is needed
Electrical burns risk for -cardiac dysrhythmias Intubated for singed nasal hairs because -inhalation injury causes edema can cause breathing problems Chemical burn priority -neutralize chemical Skin integrity, most important thing to worry about is -infection Inhalation injury, priority -100% humidified O Pulmonary tests for inhalation injury -ABG’s and bronchoscopy Deep partial thickness -red, shiny, fluid filled blisters Circumferential burn on extremity -monitor distal pulses Hypovolemia -capillary permeability, fluid into interstitium Fluid assessment -hourly UO Restless -check O2 sat Infection control with burn -PPE Zantac with burn for -stress or curling’s ulcer Kidney transplant, teaching neeed when -after a few years, I can stop taking medication Burn, pain meds -drug and alcohol increase dose, increase dose b/c of metabolic rate, give before debridement RN instruct LPN to -wash hands Postrenal -renal calculi Lasix AE -monitor I&O Prevent kidney damage -no NSAIDS