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RNSG 2539 EXAM I EXAM 2 AND EXAM 3 |
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RNSG 2539 EXAM I
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? ----CORRECT ANSWER----------Metabolic acidosis As status asthmaticus worsens, the nurse would expect which acid-base imbalance? ---
- CORRECT ANSWER----------Respiratory Acidosis Which medication classification represents a proton (gastric acid) pump inhibitor? ---- CORRECT ANSWER----------Omeprazole A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond? ----CORRECT ANSWER----------Bicarbonate-carbonic acid buffer system Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes? ----CORRECT ANSWER----------The client has eaten and has not taken or received insulin. A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? ----CORRECT ANSWER----------Regular
A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance? ----CORRECT ANSWER----------respiratory acidosis A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: ----CORRECT ANSWER----------respiratory alkalosis A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? ----CORRECT ANSWER----------Metabolic alkalosis Vomiting results in which of the following acid-base imbalances? ----CORRECT ANSWER----------Metabolic Alkalosis When explaining how carbon dioxide combines with water to form carbonic acid as part of an acid-base lecture, the faculty instructor emphasizes that which enzyme is needed as a catalyst for this reaction? ----CORRECT ANSWER----------Carbonic anhydrase A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? ----CORRECT ANSWER----------Regular A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention? ----CORRECT ANSWER---------- Request an order from the physician for IV rehydration therapy.
Decreases Levels: Phenytoin & Rifampin Serolimus & Everolimus -----------------------------------------------------Class mTOR inhibitors Indictation: Immunosuppressant, used to reduce chances of donor organ rejection SE: Hyperlipidemia, Rash, acne, anemia, thrombocytopenia, joint pain, diarrhea, hypokalemia Side effects of Everolimus -----------------------------------------------------Peripheral edema (45%) Constipation (38%) Hypertension (30%) Nausea (29%) Anemia (26%) Urinary tract infection (22%) Hyperlipidemia (21%) Cytotoxic Drug Therapy Side Effects ----------------------------------------------------- Neutropenia Thrombocytopenia Mutagenic and teratogenic Neoplasms Muromonab, Thymoglobulin -----------------------------------------------------Class: Monoclonal and Polyclonal antibodies Indications: Immunosuppressant SE: Flu like symptoms , HA, myalgia, allergic response
RN Indication: Administer over 4-6 hours. Pre-medicate with Acetaminophen and Diphenhydramine Indications for PEP -----------------------------------------------------Start 1-2 hours post exposure. No more than 72 hours Take for 28 days Test for HIV at exposure, 6&12 weeks after and 6 months after Occupational PEP -----------------------------------------------------No PEP 2 NRTIs (eg, emtricitabine plus tenofovir) PI-based regimen (eg, lopinavir/ritonavir plus emtricitabine plus tenofovir) Non-Occupational PEP -----------------------------------------------------Two three-drug regimens are preferred tenofovir/emtricitabine (Truvada) -----------------------------------------------------Brand Name: Truvada Indication: Pre-exposure Prophylaxis Only indicated for men who have sex with men Can reduce risk up to 70% Efavirenz (Sustiva) -----------------------------------------------------Class: NNRTI IndicationInhibit synthesis of HIV DNA SE: Insomnia, dreams hallucination, Rash, Teratogenicity Interactions decreases hormonal contraception effectiveness. teach pt safe sex methods or backup contaceptive
Indication: decrease GI flora in pt with Hepatic Encephalopathy SE: Ototoxicity, Nephrotoxicity, Rashes, neutropenia Common topical agents to treat pruritis associated with Jaundice ------------------------------ -----------------------Camphor Menthol Phénol Pramoxine Diphenhydramine Benzocaine Drugs commonly given to increase appetite ----------------------------------------------------- Megastrol , oxandrolone, or dronabinol Function of Neomycin on liver failure -----------------------------------------------------Decrease bacterial flora, thus reducing formation of ammonia Function of Lactulose on and liver failure ----------------------------------------------------- Acidification of feces in bowel and trapping of ammonia, causing its elimination in feces Function of Vasopressing and Propanolol in CLD --------------------------------------------------- --Hemostasis and control of bleeding by constricting the blood vessels Zidovudine Emtricitabine Tenofovir -----------------------------------------------------Class: Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Indication ART SE: Anemia & neutropenia, Lactic Acidosis, GI problems
Contraindications: avoid other bone marrow suppressants drug of choice for reducing mother-baby transmission Efavirenz (Sustiva) -----------------------------------------------------Class: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Indication: ART SE: Decreases birth control effectiveness, CNS probs, rash, tetarogenic DO NOT take while pregnant, backup birth control needed * Saquinavir (and all of the other - vir's) -----------------------------------------------------Class* Protease Inhibitor Indication ART in conjunction with NRTIs SE Hyperglycemia/diabetes Fat malredistribution Hyperlipidemia Reduced bone density among the most effective ART drugs available. Can reduce viral load to undetectable Raltegravir -----------------------------------------------------Class: HIV Integrase Strand Transfer Inhibitors Indication: ART therapy SE: Insomnia, headache, and rare hypersensitivity reactions Enfuvertide (Fuzeon) (AKA. T-20) -----------------------------------------------------Class: Fusion Inhibitor Also known as T-20 Route SUB Q BID SE Injection-site reactions, pneumonia, and hypersensitivity reactions
How to measure pulse pressure - ANSWER- Usually about 1/3 of the systolic blood pressure (ex 120/80 --> PP = 40) How to calculate MAP - ANSWER- (2DBP + SBP) / Normal MAP range - ANSWER- 60 - 110 Normal range for BNP - ANSWER- <100 = normal Common emergency medications for an MI - ANSWER- Oxygen Nitroglycerine Morphine Aspirin 162- 325 mg Non-specific marker of CAD Used to indicate inflammation Produced by the liver - ANSWER- C-reactive protein Relationship between gradual/sudden onset CAD and collateral circulation - ANSWER- Gradual onset of CAD allows for the arteries to develop collateral circulation and the body may still receive adequate O Sudden onset CAD may not allow time for collateral circulation to develop and the body may not receive an adequate amount of O Non-modifiable risk factors associated with CAD - ANSWER- White men have highest incidence African Americans have an earlier onset Gender differences associated with CAD - ANSWER- MEN More likely to experience MI first time vs Angina Report more typical S&S of angina and MI WOMEN Experience onset typically 10 yrs later than men Seek help later than men First event is usually unstable angina Higher mortality rate from CABG Clinical presentations of chronic stable angina - ANSWER- Pain that occurs intermittently over a period of time and is relieved by rest Occurs with increased physical demand
Does not change with positioning and described as tightness may radiate to jaw, neck, shoulders or arms women often report atypical symptoms such as dyspnea and fatigue = angina equivalent ST segment depression or T wave inversion Controlled with drugs on outpatient basis and taken at a specific time Prinzmetals Angina Manifestations - ANSWER- Occurs at rest May be relieved with mild exercise Cyclic, short burst of pain at same time each day CC blockers and nitrates used to control pain Drug alert for Nitrates - ANSWER- 1. Must be kept in a cool, dark place
- Do not combine with viagra
- Monitor for hypotension
- headaches are common Cardiac Catheterization Indications - ANSWER- Contrast dye is used (ask pt about allergies - may need to be treated with corticosteroids prior to procedure Patients with CKD need fluids before and after surgery Baseline serum creatinine prior to surgery to monitor kidney function Emergency equipment must be in room - code cart PCI (balloon angioplasty) Considerations - ANSWER- Anticoagulants (Hep & Lov) + Bivalirudin or Eptifibatide Dual antiplatelets post procedure (ASA indefinitely and Clopidogrel up to 12 months until smooth vascular surface has formed) Clinical Manifestations of Unstable Angina - ANSWER- New onset, increases in frequency Usually lasts 10 mins or more Prompt tx required MI Etiology - ANSWER- Usually caused by preexisting CAD STEMI
6 Weeks Area has healed ACE inhibitors given to limit ventricular remodeling Dysrhythmias associated with MI - ANSWER- V-Tach and V-Fib most common causes of death (most often occur 4 hours after onset of pain) PVCs may precede VT or VF Bradycardia okay to see PVCs and asymptomatic, nonsustained VT during reperfusion period HF manifestations associated with MI - ANSWER- S3 and S4 heard Left Sided Mild dyspnea, restlessness, agitation, tachycardia, crackles, orthopnea Right Sided JVD, lower extremity edema Therapeutic Hypothermia Procedure - ANSWER- used to lower body temp for pt's after cardiac arrest Done for 24 hours after return of spontaneous circulation in patients who do not regain consciousness 3 stages: induction, maintenance and rewarming goal core temp 89.6 - 93.2 (32-34 C)
- Patients require intubation and ventilation
- Invasive monitoring and continuous assessment Papillary Muscle Dysfunction or Rupture - ANSWER- suspect if you hear a new murmur at cardiac apex ECG to confirm diagnosis Immediate, massive mitral valve regurgitation with no time for the heart to compensate dyspnea, pulmnonary edema and decreased CO Pt undergoes rapid clinical decline *Tx: afterload reduction c̅ nitroprussides and/or IABP therapy
Left Ventricular Aneurysm - ANSWER- May hide blood clots Anticoagulants if not contraindicated ECG findings for STEMI vs NSTEMI - ANSWER- STEMI
- First ST elevation
- T wave inversion
- Q waves NSTEMI
- ST depression
- T wave inversion Cardiac Specific Troponin Test - ANSWER- Gold standard test for STEMI diagnosis
- Greater specicifity and sensitivity
- increase in 4-6 hours
- peak in 10-12 hours
- return to baseline in 10-14 days drawn q6h x4 = over 24 hours CK-MB Test - ANSWER- - begin to rise 6 hours after MI
- peak at 18 hours
- return to baseline within 24-36 hours Myoglobin Test - ANSWER- first biomarker to be seen for MI- within 2 hours
- not specific or reliable
- peaks in 3-15 hours Interprofessional Care for ACS - ANSWER- - baseline bloodwork and vitals
- 12 lead ECG
- 2 IV sites
- SL NTG and Aspirin
- High dose Atorvastatin
- Morphine for pain Glycoprotein IIb/IIIa inhibitors (Eptifibatide) before or during PCI
- Maintain BR and limit activity for 12-24 hours -- increase gradually
- upright with O2 therapy (keep above 93%)
Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) - ANSWER- available to pt's with disease of left anterior descending artery or right coronary artery (LDA or RCA)
- Some pt's may also undergo a PCI at the same time Off-Pump Coronary Artery Bypass (OPCAB) - ANSWER- - Done on beating heart
- Less complications
- Done on pt's with more comorbidities who should avoid CPG Nutritional therapy post- MI - ANSWER- - Start NPO or water
- Advance to low salt, low cholesterol, low sat fat Important pt teaching regarding ACS - ANSWER- - Avoid heavy meals
- rest 1-2 hours post heavy meals
- encourage excercise
- proper use of NTG Phases of rehab after ACS - ANSWER- Phase 1: Hospital
- Pt may sit up in chair or bed
- focus on managing pain, anxiety and dysrhythmias Phase 2: Early Recovery
- Begins after pt is discharged
- 2 - 12 weeks in outpatient facility
- activity level gradually increased
- risk factor reduction info provided Phase 3: Late Recovery
- Long term maintenance
- therapeutic lifestyle changes
- medical supervision recommended Postoperative cognitive dysfunction (POCD) - ANSWER- - Can manifest days, weeks or months after CABG
- Loss in memory, concentration, language comprehension
- May cry or become teary
- May become chronic Sexual teaching regarding ACS recovery - ANSWER- - AVOID VIAGRA
- Prophylactic NTG may be used
- Positions up to couple
- Postpone after a big meal
- Avoid anal sex - vagal response
- Avoid hot/cold showers
- Foreplay and masturbation desirable
Sudden Cardiac Death (SCD) Etiology - ANSWER- - Occurs in anyone
- May not have preexisting heart problems
- Death occurs within 1 hour risk factors include:
- Male gender
- African American
- Hx of syncope
- Family hx of dysryhthmias Nursing Management of SCD - ANSWER- - Diagnostic testing with serial biomarkers
- ECGs
- Cardiac cath, PCI or CABG
- 24 hour Holter monitor
- Stress test
- ICD with amiodarone LifeVest Management with SCD - ANSWER- - Used before ICD
- Sounds alarm to signal pt unresponsive
- If pt is responsive -- presses 2 buttons to turn off
- If pt does not repsond, warning signal sent
- Shock delivered Maternal Risk Factors for Congenital Heart Defects - ANSWER- - Diabetes
- SLE
- Antiseizure meds (Phenytoin/Dilantin)
- Isoretinoin (Accutane)
- Lithium
- ETOH and Drugs
- Family history Infections
- Rubella
- Coxsackie
- Toxoplasmosis
- Parvovirus Prenatal diagnosis of Congenital Heart Defect - ANSWER- - Maternal ultrasound after 20 weeks gestation
- Fetal transabdominal echo after 16 weeks Requirements of cardiac echo for child - ANSWER- - must be kept still
- may be fussy and crying -- mild sedative
- psychological prep for older children
- movies and music
4.Patent Ductus Arteriosus* SIGNS AND SYMPTOMS Boggy lungs tachypnea tachycardia increased caloric expenditure poor cellular nutrition Atrial Septal Defect (ASD) - ANSWER- Increased Pulmonary Blood Flow Defect Clinical Manifestations:
- May be asymptomatic
- May develop HF
- Characteristic systolic murmur
- At risk for atrial dysrhythmias and emboli formation Treatment:
- Surgical patch closure (Pericardial/ Dacron)
- Open repair with CPB before school age
- ASD 2 closed with cardiac cath in outpatient setting
- Pt's receive low dose Aspirin for 6 months
- Mortality rate low Ventricular Septal Defect (VSD) - ANSWER- Increased Pulmonary Blood Flow Defect Clinical Manifestations
- Membranous (80%) or Muscular
- Frequently associated with other defects
- Many close spontaneously (most likely to occur in 1st year or life)
- HF common
- Holosystolic murmur at left sternal border Surgical Treatment (done with CPB) Palliative - Pulmonary artery banding Complete Repair - Sutures or Dacron patch Nonsurgical - being done at some centers through cardiac cath Mortality rate relatively low. Increases with comorbidities
S&S of VSD - ANSWER- Holosystolic murmur/ hum/ thrill Seating & fatigue during feedings Respiratory infections Growth delay Bounding pulses Low diastolic arterial pressure Pulmonary edema Tachypnea Tachycardia Poor feeding Diaphoresis Irritability Treatment of VSD - ANSWER- Concentrated calories in feeding Diuretics Afterload reduction Complete repair in infancy with a patch Patent Ductus Arteriosus (PDA) - ANSWER- Increased Pulmonary Blood Flow Defect
- Failure of the fetal ductus arteriosus to close within the first weeks of life Clinical Manifestations:
- May be asymptomatic or SS of HF
- Machinery like murmur
- Widened PP and bounding pulses Treatment Medications: IV ibuprofen & Indomethacin Surgery: Surgical division or ligation via left thoractomy Nonsurgical: Coils placed in cath lab (preterm or complicated cases may need surgery) Decreased Pulmonary Blood Flow Defects - ANSWER- Tetralogy of Fallot Tricuspid Atresia Pulmonic stenosis
- Result in Cyanosis
- Blood has difficulty exiting right side of the heart
- Right side pressure exceeds left
- Right to left shunting
- Patients have hypoxemia and are cyanotic
- Increased Hct
- Clots may form Coarctation of the Aorta - ANSWER- Decreased Pulmonary Blood Flow Defect
