Term
| nursing diagnoses for disruption of oxygenation |
|
Definition
- ineffective airway clearance
- ineffective breathing patterns
- impaired gas exchange
- decreased cardiac output
- impaired tissue perfusion: cardiopulmonary |
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Term
|
Definition
| volume of air inspired and expired with each breath during normal breathing |
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Term
|
Definition
the volume of air expired per minute
TV x RR |
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Term
|
Definition
| - measured by having the patient take in a maximal breath and exhale fully through a spirometer |
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Term
|
Definition
| evaluates the effort the patient is making during inspiration |
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
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Term
| causes of respiratory acidosis |
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Definition
- respiratory depression
- decreased ventilation
- altered diffusion |
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Term
| s/s of respiratory acidosis |
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Definition
- feeling full in the head
- mental cloudiness
- muscular twitching
- convulsions
- warm flushed skin
- unconsciousness
- V-fib |
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Term
| causes of respiratory alkalosis |
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Definition
- anxiety
- fear
- pain
- hypoxia
- head injury
- fever
- too much mechanical ventilation |
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Term
| s/s of respiratory alkalosis |
|
Definition
- lightheadedness
- inability to concentrate
- numbness/tingling of extremities (decreased calcium ion)
- circumoral paresthesia (decreased calcium ion) |
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Term
| causes of metabolic acidosis |
|
Definition
- gain of strong acid
- loss of bicarb
- ketoacidosis
- lactic acidosis
- late phase of salicylate poisoning
- uremia
- methanol/ethylene glycol toxicity
- ketoacidosis with starvation |
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Term
| s/s of metabolic acidosis |
|
Definition
- headache
- confusion
- drowsiness
- increased RR and depth
- n/v
- peripheral vasodilation (warm flushed)
- decreased cardiac output if pH falls below 7.1 |
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|
Term
| causes of metabolic alkalosis |
|
Definition
- loss of strong acid
- gain of bicarb
- vomiting (most common)
- gastric suction with loss of H+ and Cl-
- pyloric stenosis
- use of diuretics |
|
|
Term
| s/s of metabolic alkalosis |
|
Definition
- depressed respiration
- dizziness (decreased calcium)
- tingling (decreased calcium)
- circumoral paresthesia (decreased calcium)
- carpopedal spasm (decreased calcium)
- hypertonic muscles (decreased calcium) |
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Term
|
Definition
respiratory = opposite
metabolic = equal |
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Term
|
Definition
PaO2 < 50 mm Hg with FiO2 > 60
PaO2 > 50 mm Hg with pH < 7.25
vital capacity < 2x tidal volume
negative inspiration force < 25 cm H2O
respiratory rate > 35/min |
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Term
| negative pressure ventilators |
|
Definition
- exert negative pressure on external chest
- decrease intra-thoracic pressure during inspiration |
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Term
| examples of negative pressure ventilators |
|
Definition
- iron lung
- body wrap
- chest cuirass |
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Term
| conditions indicating negative pressure ventilators |
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Definition
- polio
- muscular dystrophy
- amyotrophic lateral sclerosis
- myasthenia gravis |
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Term
| positive pressure ventilators |
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Definition
- delivers constant pressure
- used in adults with ARDS, have to be intubated or trached |
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Term
| types of positive pressure ventilators |
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Definition
- pressure-cycled
- time-cycled
- volume-cycled
- non-invasive |
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Term
| assist-control ventilation |
|
Definition
- provides full ventilatory support
- delivers preset TV and RR
- if patient initiates breath, ventilator delivers at preset volume |
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Term
| intermittent mandatory ventilation (IMV) |
|
Definition
- combination of mechanically assisted breaths and spontaneous breaths
-mechanical breaths are delivered at preset time and TV
- if patient initiates breath, TV depends on patient
- helps prevent muscle atrophy
- bucking the ventilator (trying to exhale when ventilator is delivering a breath) may increase
- full or partial support |
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Term
| synchronized intermittent mandatory ventilation (SIMV) |
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Definition
- delivers preset TV and RR
- patient can breathe spontaneously
- machine senses patient's breath so bucking the ventilator is reduced
- full or partial support |
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Term
| pressure support ventilation (PSV) |
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Definition
- pressure plateau
- pressure support is decreased as patient's strength increases
- patient's TV and RR must be closely monitored to prevent tachypnea or large tidal volumes |
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Term
| airway pressure release ventilation (APRV) |
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Definition
- time-triggered
- pressure-limited
- time-cycled
- allows unrestricted spontaneous breathing |
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Term
|
Definition
- displacement
- obstruction
- pneumothorax
- equipment failure |
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Term
The most common cause of a low-pressure alarm on a positive pressure ventilator would be:
A. client is anxious and fights the ventilator
B. the endotracheal tube is displaced
C. there is a disconnect or leak in the ventilator circuit
D. increased secretions in the airway |
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Definition
| C. there is a disconnect or leak in the circuit |
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Term
|
Definition
| occurs when the parietal or visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure |
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Term
|
Definition
- simple
- traumatic
- tension
- hemothorax |
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Term
|
Definition
| a build-up of blood or other fluid in the pericardial sac puts pressure on the heart, which may prevent it from pumping effectively |
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Term
A nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A. a low respiratory rate
B. diminished breath sounds
C. the presence of a barrel chest
D. a sucking sound at the site of the injury |
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Definition
| B. diminished breath sounds |
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Term
| symptoms of adult respiratory distress syndrome (ARDS) |
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Definition
- tachypnea
- dyspnea
- tachycardia
- initially respiratory alkalosis followed by respiratory acidosis
- increasing hypoxia
- chest x-ray shows infiltrates in lungs |
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Term
A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:
A. promote oxygen uptake
B. strengthen the diaphragm
C. strengthen the intercostal muscles
D. promote carbon dioxide elimination |
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Definition
| D. promote carbon dioxide elimination |
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Term
| characteristics of chest pain |
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Definition
- onset
- precipitating factors
- duration
- relieving factors
- location
- radiation
- quality
- intensity |
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Term
A client with no history of cardiovascular disease comes to the abulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate pain caused by a non-cardiac problem?
A. Can you describe the pain to me?
B. Have you ever had this pain before?
C. Does tha pain get worse when you breathe in?
D. Can you rate the pain on a scale of 1 to 10? |
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Definition
| C. Does the pain get worse when you breathe in |
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Term
|
Definition
- smoking
- elevated cholesterol
- hypertension
- diabetes
- family history
- gender
- stress
- obesity
- sedentary lifestyle |
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Term
| stable angina characteristics |
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Definition
- predictable
- consistent
- occurs on exertion
- relieved by rest and nitro |
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Term
| unstable angina characteristics |
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Definition
- increases in frequency and severity
- not relieved by rest or nitro |
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Term
|
Definition
| acute onset of myocardial ischemia that results in myocardial death if appropriate interventions do not take place |
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Term
|
Definition
- ST segment elevation myocardial infarction
- EKG changes & elevation in cardiac enzymes
- troponin
- emergent treatment |
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Term
|
Definition
- non-ST segment elevation MI
- non-emergent treatment |
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Term
|
Definition
| inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygenation and nutrients |
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Term
|
Definition
- edema
- weight gain
- fatigue
- activity intolerance
- dyspnea
- ascites
- enlarged liver
- orthopnea
- jugular vein distention |
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Term
|
Definition
- evaluates cardiac valves
- assesses left ventricular function
- less than 40% = heart failure |
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Term
|
Definition
a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens
<100 is normal |
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Term
|
Definition
- synthetic BNP
- reduced preload/afterload
- rapid improvement
- must be hospitalized
- used for treatment of CHF |
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Term
|
Definition
- phosphodiesterase inhibitor
- vasodilation
- decreased preload/afterload
- reduces cardiac workload |
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Term
|
Definition
- catecholamine that stimulates beta-1 adrenergic receptors
- increases cardiac contractility
- positive inotrope |
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Term
|
Definition
| widespread perfusion to the cells is inadequate to deliver oxygen and nutrients to vital organs |
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Term
|
Definition
- septic
- hypovolemic
- cardiogenic
- neurogenic
- anaphylaxis |
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Term
|
Definition
| hypoperfusion state causes hypoxia. due to the lack of oxygen, the cell membranes become damaged, they become leaky to extra-cellular fluid, and the cells perform anaerobic respiration. this causes a build-up of lactic and pyruvic acid which results in systemic metabolic acidosis |
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Term
| compensatory stage of shock |
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Definition
| body employs physiological mechanisms, including neural, hormonal and biochemical mechanisms in an attempt to reverse the condition |
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Term
| progressive stage of shock |
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Definition
| compensatory mechanisms fail. prolonged vasoconstriction will also cause the vital organs to be compromised due to reduced perfusion. |
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Term
| refractory stage of shock |
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Definition
| vital organs have failed. shock can no longer be reversed. most cellular ATP has been degraded into adenosine in the absence of oxygen. |
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Term
|
Definition
- hemodynamic instability
- oxygenation issues
- decreased urinary output
- confusion
- acid base imbalance
- cool/clammy |
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Term
|
Definition
- treat underlying cause!
- recognize progression
- supportive care
- if sepsis, antibiotics
- fluid resuscitation
- vasopressors
- mechanical ventilation |
|
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Term
|
Definition
- dobutamine
- dopamine
- epinephrine
- milrinone |
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|
Term
|
Definition
- nitroglycerin
- nitroprusside |
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|
Term
|
Definition
- norepinephrine
- dopamine
- phenylephrine
- vasopressin |
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Term
|
Definition
- whole blood
- packed red blood cells
- platelets
- fresh frozen plasma
- albumin |
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Term
|
Definition
- cells and plasma
- hematocrit is approx. 40%
- used for significant blood loss |
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Term
| packed red blood cells (PRBC) |
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Definition
- RBCs with little plasma
- used for severe anemia |
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Term
|
Definition
| - prevents bleed when <5000-10,000 |
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Term
|
Definition
- contains all coag factors
- used for coag factor deficiency |
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Term
|
Definition
| - used for decreased protein in blood, burns |
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Term
| blood transfusion complications |
|
Definition
- febrile nonhemolytic
- acute hemolytic
- allergic
- circulatory overload
- bacterial contamination
- transfusion-related lung injury
- delayed hemolytic
- disease acquisition |
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Term
| febrile nonhemolytic reaction |
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Definition
- caused by antibodies to donor leukocytes that remain in the unit of blood or blood component
- most common type of transfusion reaction
- more frequent in patients with previous transfusions and Rh-neg women who had Rh-pos babies |
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Term
| s/s of febrile nonhemolytic reaction |
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Definition
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Term
|
Definition
- occurs when donor blood is incompatible with recipient
- erythrocytes are destroyed
- caused by errors in blood component labeling and patient ID |
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Term
| s/s of acute hemolytic reaction |
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Definition
- fever
- chills
- low back pain
- nausea
- chest tightness
- dyspnea
- anxiety |
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Term
|
Definition
| - caused by a sensitivity reaction to a plasma protein within the blood component |
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Term
|
Definition
- urticaria
- itching
- flushing |
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Term
|
Definition
- too much blood infused too quickly
- hypervolemia
- aggravated in CHF patients |
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Term
| s/s of circulatory overload |
|
Definition
- dyspnea
- orthopnea
- tachycardia
- sudden anxiety
- jugular vein distention
- crackles at base of lungs
- hypertension |
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Term
| febrile nonhemolytic reaction prevention |
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Definition
- further depleting the blood component of donor leukocytes
- leukocyte reduction filter |
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Term
| acute hemolytic reaction prevention |
|
Definition
- meticulous attention to detail in labeling blood samples and components
- accurately IDing recipient |
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Term
| allergic reaction prevention |
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Definition
| - premedicate with antihistamines |
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Term
| circulatory overload prevention |
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Definition
- patients at risk or already in overload can be given diuretics between units of PRBCs
- titrate units to patient's tolerance
- for severe, place patient in upright position with feet in dependent position, discontinue transfusion, and call physician |
|
|
Term
|
Definition
- occurs during procurement or processing, but often results from organisms on donor's skin
- platelets are at greater risk |
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Term
| bacterial contamination prevention |
|
Definition
- meticulous care in procurement and processing of blood components
- administer transfusions within 4 hours
- discontinue transfusion as soon as reaction is IDed |
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|
Term
| s/s of bacterial contamination |
|
Definition
- fever
- chills
- hypotension |
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|
Term
| transfusion-related acute lung injury |
|
Definition
- potentially fatal, idiosyncratic reaction, very rare
- onset is abrupt (within 6 hours) |
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|
Term
| s/s of transfusion-related acute lung injury |
|
Definition
- acute SOB
- hypoxia
- hypotension
- fever
- eventual pulmonary edema |
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|
Term
| transfusion-related acute lung injury prevention |
|
Definition
- limiting the frequency/amount of blood products transfused
- obtaining plasma and possibly platelets only from either men or from women who have never been pregnant |
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|
Term
| delayed hemolytic reaction |
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Definition
| - occur within 14 days after transfusion |
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|
Term
| s/s of delayed hemolytic reaction |
|
Definition
- fever
- anemia
- increased bilirubin level
- decreased/absent haptoglobin
- possible jaundice |
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|
Term
| delayed hemolytic reaction prevention |
|
Definition
| difficult to prevent because the amount of antibody present can be too low to detect; reaction is usually mild and requires no intervention |
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|
Term
|
Definition
despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components
- hepatitis
- AIDS
- cytomegalovirus
- graft-versus-host disease
- creutzfeldt-jakob disease |
|
|
Term
| normal cardiac conduction |
|
Definition
- SA node
-> atria
-> AV node
-> bundle of HIS
-> Purkinje fibers
-> ventricles |
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|
Term
|
Definition
SA node fires, sending electric impulse outward to stimulate atria
0.10 sec |
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|
Term
|
Definition
impulse from bundle of HIS throughout ventricular muscles
<0.12 sec |
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|
Term
|
Definition
- ventricular repolarization
- resting phase of cardiac cycle |
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|
Term
| interpretation of ECG strip |
|
Definition
- heart rate
- heart rhythm
- P wave
- PRI
- QRS complex |
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|
Term
|
Definition
|
|
Term
|
Definition
- patient movement
- loose/defective electrodes
- improper grounding
- faulty ECG apparatus |
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|
Term
|
Definition
- bradycardia = <60 bpm
- normal = 60-100 bpm
- tachycardia = >100 bpm |
|
|
Term
|
Definition
- normal sinus rhythm
- sinus bradycardia
- sinus tachycardia |
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|
Term
|
Definition
- 60-100 bpm
- atrial rhythm regular
- ventricular rhythm regular
- P wave before each QRS
- P waves upright and uniform
- each PR interval is 0.12-0.20 sec
- all QRS complexes look alike
- QRS complexes are <0.12 sec |
|
|
Term
|
Definition
- <60 bpm
- atrial rhythm regular
- ventricular rhythm regular
- P wave before each QRS
- P waves upright and uniform
- PR interval is 0.12-0.20 sec
- all QRS complexes look alike
- QRS complexes are <0.12 sec |
|
|
Term
|
Definition
- parasympatholytic
- small doses inhibit salivary and bronchial secretions
- moderate doses dilate pupils and increase heart rate
- in emergency care, used to increase heart rate in life-threatening bradycardias |
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Term
|
Definition
- bradydysrhythmias
- refractory tachydysrhythmias
- prophylaxis for cardiac surgery
- heart failure - resynchronization therapy |
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|
Term
| pacemaker contraindications |
|
Definition
- active infections
- poorly controlled SVT
- atrial fibrillation |
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|
Term
|
Definition
- permanent or temporary
- provides electric stimuli to the heart muscle
- can be used in conjunction with an implantable cardioverter defibrillator |
|
|
Term
|
Definition
| monitor heart's natural electrical activity and discharge only when heart's own rate is too slow or misses a beat |
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Term
|
Definition
| discharge impulses at a single, steady rate, regardless of heart's own electrical activity |
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Term
| rate-responsive pacemaker |
|
Definition
| designed to raise or lower heart rate to help meet body's needs during physical activity or rest |
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|
Term
|
Definition
- infection
- system failure
- ventricular perforation
- thrombosis and embolism |
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|
Term
|
Definition
- 100-160 bpm
- atrial rhythm regular
- ventricular rhythm regular
- P wave before each QRS
- P waves upright and uniform
- PR interval is 0.12-0.20 sec
- all QRS complexes look alike
- QRS complexes are <0.12 sec |
|
|
Term
| sinus tachycardia treatment |
|
Definition
- beta blockers
- beta-adrenergic blocking agents |
|
|
Term
|
Definition
| block the action of endogenous catecholamines on beta-adrenergic receptors, part of the sympathetic nervous system which mediates "fight or flight" response |
|
|
Term
|
Definition
- SA node fails to generate impulse: atrial dysrhythmias
- non-lethal |
|
|
Term
|
Definition
- atrial rate 250-300 bpm
- ventricular rate varies
- atrial rhythm regular
- ventricular rhythm regular or irregular
- P waves are absent, replaced by F waves (sawtooth)
- PR interval not measurable
- all QRS complexes look alike
- QRS complexes are usually <0.12 sec |
|
|
Term
|
Definition
- beta blockers
- calcium channel blockers
- digoxin
- cardioversion |
|
|
Term
| atrial fibrillation (A-fib) |
|
Definition
- atrial rate 350-400 bpm
- ventricular rate variable
- irregularly irregular rhythm
- P waves are absent, replaced by F waves
- PR interval is not discernable
- all QRS complexes look alike
- QRS complexes are usually <0.12 sec |
|
|
Term
| atrial fibrillation treatment |
|
Definition
- rate lowering drugs
- antiarrhythmic drugs
- anticoagulants |
|
|
Term
|
Definition
- decreases conductivity of electrical impulses through SA and AV nodes
- slows down heart rate
- cardiac glycoside
- positive inotropic
- high ventricular rate leads to insufficient diastolic filling time. by slowing down the conduction in the AV node and increasing its refractory period, digoxin can reduce the ventricular rate. the arrhythmia itself is not affected, but the pumping function of the heart improves due to improved filling |
|
|
Term
|
Definition
- disrupts the movement of calcium through calcium channels
- slow down the conduction of electrical activity within the heart by blocking the calcium channel during the plateau phase of the action potential of the heart
- negative chronotropic effect, or lowering of heart rate |
|
|
Term
|
Definition
- quinidine
- procainamide
- disopyramide
- lidocaine
- mexiletine
- tocainide
- flecainide
- propafenone
- moricizine |
|
|
Term
| beta adrenergic receptor antagonists |
|
Definition
|
|
Term
| prolong refractoriness drugs |
|
Definition
- amiodarone
- bretylium
- sotalol |
|
|
Term
|
Definition
|
|
Term
|
Definition
- class III antiarrhythmic agent
- prolongs phase 3 of cardiac action potential
- available IV or PO |
|
|
Term
|
Definition
- anticoagulant
- treats current clots and prevents |
|
|
Term
| supraventricular tachycardia (SVT) |
|
Definition
- atrial and ventricular rate 150-250 bpm
- rhythm regular
- P waves usually not discernible
- PR interval usually not discernible
- all QRS complexes look alike
- QRS complexes are usually <0.12 sec |
|
|
Term
| supraventricular tachycardia treatment |
|
Definition
- cardioversion
- adenosine (causes transient heart block in AV node) |
|
|
Term
|
Definition
| - SA node or AV junctional tissue fails to initiate electrical impulse |
|
|
Term
| premature ventricular complexes (PVC) |
|
Definition
- rate is dependent on rate of underlying rhythm and number of PVCs
- rhythm is occasionally irregular; regular if interpolated PVC
- no P waves with PVC; P waves of underlying rhythm may be present
- PR interval not present with PVCs
- QRS complexes wide and bizarre
- QRS complexes >= 0.12 sec |
|
|
Term
|
Definition
- electrolytes
- eliminate caffeine, alcohol, drugs
- antiarrhythmics DO NOT WORK
- may use beta blockers |
|
|
Term
| ventricular tachycardia (VT) |
|
Definition
- 100-250 bpm
- atrial rhythm not distinguishable
- ventricular rhythm usually regular
- P waves may be present or absent
- no PR interval
- all QRS complexes look alike except in torsades rhythm, bizarre
- QRS complexes are >0.12 sec |
|
|
Term
| ventricular tachycardia treatment |
|
Definition
- sustained v. nonsustained
- symptomatic
- pulseless
- defibrillator
- CPR
- amiodarone |
|
|
Term
| ventricular fibrillation (v-fib) |
|
Definition
- rate cannot be discerned
- rhythm is rapid, unorganized, not distinguishable
- no PR interval
- no QRS complex |
|
|
Term
| ventricular fibrillation treatment |
|
Definition
- immediate defibrillator
- amiodarone
- vasopressors
- ACLS protocol
- give magnesium for torsades |
|
|
Term
|
Definition
- rate absent
- rhythm absent
- no P wave
- no PR interval
- no QRS complex |
|
|
Term
|
Definition
|
|
Term
A client's EKG strip shows atrial and ventricular rates of 110 bpm. The PR interval is 0.14 sec, the QRS complex measures 0.08 sec, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
A. sinus arrhythmia
B. sinus tachycardia
C. sinus bradycardia
D. normal sinus rhythm |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| conduction through the AV node |
|
|
Term
|
Definition
| force of myocardial contraction |
|
|
Term
|
Definition
| sympathetic nervous system (increases) |
|
|
Term
|
Definition
| parasympathetic nervous system (decreases) |
|
|
Term
|
Definition
- sympathomimetic
- inotropic agent
- synthetic derivative of isoproterenol
- decreases afterload
- stimulates beta adrenergic receptors to increase myocardial contractility
- alpha adrenergic receptors increase BP at low dose |
|
|
Term
|
Definition
- sympathomimetic
- beta receptors: increases myocardial contractility
- alpha receptors: vasoconstriction |
|
|
Term
|
Definition
- sympathomimetic
- stimulates beta adrenergic receptors
- increases myocardial contractility
- positive chronotrope
- positive dromotrope
- bronchodilator
- used to treat bradycardias, severe left ventricular dysfunction, anaphylaxis
- stimulates alpha adrenergic receptors
- vasoconstriction
- used in profound hypotension or pulseless cardiac arrest to promote systemic perfusion pressure gradient |
|
|
Term
| norepinephrine (levophed) |
|
Definition
- sympathomimetic, vasopressor
- stimulates alpha adrenergic receptors, producing vasoconstriction and decreased HR
- at low doses, stimulates beta adrenergic receptors to enhance myocardial contractility |
|
|
Term
| sodium nitroprusside (nipride) |
|
Definition
- vasodilator
- relaxes arterial and venous smooth muscle to decrease preload/afterload
- decreases pulmonary artery pressure
- enhanced renal blood flow
- enhanced coronary blood flow
- antihypertensive |
|
|
Term
|
Definition
- vasodilator
- relaxes arterial and venous smooth muscle to decrease preload with mild afterload reduction
- decreases pulmonary vascular resistance
- coronary vasodilation
- improves ventricular compliance |
|
|
Term
| phenylephrine (neosynephrine) |
|
Definition
- sympathomimetic, vasopressor
- stimulates alpha adrenergic receptors
- vasoconstriction
- decreased heart rate
- increased peripheral resistance
- used to increase BP |
|
|
Term
|
Definition
- inotropic agent
- phosphodiesterase inhibitor
- increases contractility and cardiac index
- lowers capillary wedge pressure
- lowers pulmonary artery pressures
- increases rate of myocardial relaxation |
|
|
Term
|
Definition
- antidiuretic hormone
- stimulates vascular vasopressin V receptors to cause vasoconstriction
- tends to not cause HTN in normotensive patients
- stimulates vasopressin V receptors in the renal tubules to cause fluid retention and prevent fluid loss
- no alpha or beta adrenergic receptor activity |
|
|
Term
|
Definition
- et tube goes through mouth or nose into trachea
- balloon is inflated after insertion
- check pressures q4h
- pressure should be 12-25 mm Hg
- use for less than 3 weeks |
|
|
Term
| s/s of increased tube pressures |
|
Definition
- trach bleeding
- ischemia
- pressure
- necrosis |
|
|
Term
| s/s of decreased tube pressures |
|
Definition
|
|
Term
| disadvantages of intubation |
|
Definition
- discomfort/cough reflex decreased
- secretions increase
- swallowing reflexes gone
- if taken out too early, can arrest |
|
|
Term
|
Definition
- thoracic/abdominal surgery
- drug overdose
- neuromuscular disorders
- inhalation injuries
- COPD
- multitrauma
- shock |
|
|
Term
Which patient would potentially require intubation?
A. pO2=88, pCO2=43, FiO2=40%, pH=7.38, RR=18
B. pO2=61, pCO2=53, FiO2=75%, pH=7.31, RR=30
C. pO2=163, pCO2=33, FiO2=50%, pH=7.46, RR=22 |
|
Definition
| B. pO2=61, pCO2=53, FiO2=75%, pH=7.31, RR=30 |
|
|
Term
| noninvasive ventilation candidates |
|
Definition
- COPD
- chronic respiratory failure
- acute pulmonary edema
- chronic heart failure |
|
|
Term
|
Definition
-spontaneous ventilations with continuous positive airway pressure
- only for spontaneous breathing patients
- patient breaths on own through ventilator at increased baseline pressure through cycle |
|
|
Term
|
Definition
- positive end expiratory pressure
- at the end of expiration, airway is not allowed to return to 0 functional residual capacity |
|
|
Term
|
Definition
| preset volume of gas given under positive pressure while spontaneous patient effort is locked out |
|
|
Term
| assist/control ventilation |
|
Definition
| preset volume of gas delivered to patient at preset rate. but patient may trigger vent breaths with neg. inspiratory effort |
|
|
Term
|
Definition
| preset minimum of breaths are synchronized as delivered to the patient, but patient may also take spontaneous breaths of varying volume |
|
|
Term
| pressure support ventilation |
|
Definition
| patient breathes spontaneously with pressure assistance to each spontaneous inspiration |
|
|
Term
Which ventilator mode allows a patient to take a spontaneous breath with minimal assistance above and beyond the rate set on the ventilator?
A. control mode
B. assist control mode
C. SIMV
D. pressure regulated volume control |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Nesiritide (Natrecor) cautions |
|
Definition
- monitor BP: can cause hypotension
- do not infuse with other drugs
- SE: hypotension, tachycardia, a-fib, tremor, cough, apnea, rash, leg cramps, anemia |
|
|
Term
| alpha adrenergic receptors |
|
Definition
- skin
- muscles
- kidneys
- intestine |
|
|
Term
| beta 1 adrenergic receptors |
|
Definition
- cardiac tissue
- increased HR, conduction, and contractility |
|
|
Term
| beta 2 adrenergic receptors |
|
Definition
| - vascular/bronchial smooth muscle |
|
|
Term
|
Definition
- dobutamine
- dopamine
- epinephrine
- isoproterenol
- norepinephrine |
|
|
Term
|
Definition
- enhance myocardial contractility
- positive inotropes
- increase cardiac output |
|
|
Term
|
Definition
- parietal or visceral pleura is breached and pleural space is exposed to positive atmospheric pressure
- air enters and lung collapses |
|
|
Term
|
Definition
- spontaneous
- breach of parietal or visceral pleura
- due to bleb/bronchopleural fistula
- air enters pleural cavity |
|
|
Term
|
Definition
- air enters from laceration in lung
- due to blunt or penetrating trauma
- usually accompanied by hemothorax |
|
|
Term
|
Definition
- air goes in/out with each breath
- considered "sucking" chest wound
- if large, ARDS occurs
- everything shifts to uninjured side with inspiration and opposite side with expiration |
|
|
Term
|
Definition
| - bleeding into the pleural space |
|
|
Term
|
Definition
- hypotension
- hypovolemia
- shock
- decreased cardiac output
- tissue ischemia
- IVs and chest tube insertion on affected side |
|
|
Term
|
Definition
- perforates chest wall and pleural space
- air flows in pleural space with inspiration of lung on injured side
- pressure pushes on heart and thoracic area
- leads to decreased venous return, cardiac output, and oxygenation
- can't offer oxygen |
|
|
Term
| s/s of tension pneumothorax |
|
Definition
- dyspnea
- increased HR
- hypotension
- sudden chest pain
- tracheal deviation (late sign)
- decreased/absent breath sounds on injured side |
|
|
Term
|
Definition
- fatigue
- dependent edema
- RUQ pain
- anorexia
- GI bloating
- nausea |
|
|
Term
|
Definition
| right sided heart failure |
|
|
Term
|
Definition
- fatigue
- dyspnea
- orthopnea
- dry, hacking cough
- pulmonary edema
- nocturia
- decreasing renal function |
|
|
Term
A client is being treated for acute congestive heart failure with IV bumetanide (Bumex). The vital signs are as follows: BP 100/60, HR 96 bpm, and RR 24 breaths/min. After the initial dose, which of the following is the priority assessment?
A. monitoring weight loss
B. monitoring urine output
C. monitoring blood pressure
D. monitoring potassium level |
|
Definition
| C. monitoring blood pressure |
|
|
Term
|
Definition
- digitalis glycosides
- inotropic drugs
- mechanical assistive devices |
|
|
Term
|
Definition
- antiplatelet
- nitrates
- beta blockers
- calcium channel blockers |
|
|
Term
| s/s of myocardial infarction |
|
Definition
- chest pain
- apprehension
- nausea and vomiting
- dyspnea
- diaphoresis
- extreme fatigue
- dizziness/faintness |
|
|
Term
|
Definition
| decreased intravascular volume due to fluid loss |
|
|
Term
|
Definition
| impairment/failure of myocardium |
|
|
Term
|
Definition
| overwhelming infection causing relative hypovolemia |
|
|
Term
|
Definition
| loss of sympathetic tone causing relative hypovolemia |
|
|
Term
|
Definition
| severe allergic reaction producing overwhelming systemic vasodilation, relative hypovolemia |
|
|
Term
| multiple organ dysfunction syndrome |
|
Definition
| presence of altered function of 2 or more organs in acutely ill patient such that interventions are necessary to support continued organ function |
|
|
Term
| compensatory stage of shock |
|
Definition
- vasoconstriction
- increased HR
- increased contractility |
|
|
Term
| s/s of compensatory shock |
|
Definition
- cool clammy skin
- hypoactive bowel sounds
- decreased urine output |
|
|
Term
| progressive stage of shock |
|
Definition
| mechanisms that regulate BP and no longer compensate, BP and MAP decrease |
|
|
Term
Which stage of shock is characterized by a normal blood pressure?
A. initial
B. compensatory
C. progressive
D. irreversible |
|
Definition
|
|
Term
| general management strategies in shock |
|
Definition
- fluid replacement
- vasoactive medication therapy
- nutritional support |
|
|
Term
| medical management of cardiogenic shock |
|
Definition
- oxygenation
- pain control
- hemodynamic monitoring
- laboratory marker monitoring
- fluid therapy
- mechanical assistive devices |
|
|
Term
| pharmacologic therapy for cardiogenic shock |
|
Definition
- dobutamine
- nitroglycerin
- dopamine
- vasoactive medications
- antiarrhythmic medications |
|
|
Term
| nursing management for cardiogenic shock |
|
Definition
- preventing cardiogenic shock
- monitoring hemodynamic status
- administering medications, IV fluids
- maintaining intra-aortic balloon counter pulsation
- ensuring safety, comfort |
|
|
Term
| True or false: the most common colloid solution used to treat hypovolemic shock is 5% albumin. |
|
Definition
| True: the most common colloid solution used to treat hypovolemic shock is 5% albumin. |
|
|
Term
| true or false: the primary goal in treating cardiogenic shock is to limit further myocardial damage. |
|
Definition
| false: the primary goal in treating cardiogenic shock is not to limit further myocardial damage. the primary goal in treating cardiogenic shock is to treat the oxygenation needs of the heart muscle. |
|
|
Term
| the QRS complex represents? |
|
Definition
| ventricular depolarization |
|
|
Term
|
Definition
| ventricular repolarization |
|
|
Term
|
Definition
|
|
Term
A client admitted with acute anxiety has the following ABG values: pH 7.55, paO2 90, paCO2 27, bicarb 24. Based on these values, the nurse suspects:
A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis |
|
Definition
D. respiratory alkalosis
This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. |
|
|
Term
When a client's ventilation is impaired, the body retains which substance?
A. sodium bicarbonate
B. carbon dioxide
C. nitrous oxide
D. oxygen |
|
Definition
B. carbon dioxide
When ventilation is impaired, the body retains carbon dioxide because the carbonic acid level increases in the blood. |
|
|
Term
A client is recovering from an acute myocardial infarction. During the first week of recovery, the nurse should stay alert for which abnormal heart sound?
A. opening snap
B. Graham Steell's murmur
C. ejection click
D. pericardial friction rub |
|
Definition
D. pericardial friction rub
A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. |
|
|
Term
After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine (Dobutrex), 5 mcg/kg/minute IV. Which classification best describes dobutamine?
A. indirect-acting dual-active agent
B. direct-acting geta-active agent
C. indirect-acting beta-active agent
D. direct-acting alpha-active agent |
|
Definition
B. direct-acting beta-active agent
Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent. Adrenergic agents are classified according to their method of action and the type of receptor they act on. Direct-acting agents act directly on the sympathetically innervated organ/tissue. |
|
|
Term
A client with a pulmonary embolus has the following ABG values: pH 7.49, paO2 60, paCO2 30, bicarb 25. What should the nurse do first?
A. instruct the client to breathe into a paper bag
B. administer oxygen by nasal cannula as prescribed
C. auscultate breath sounds bilaterally every 4 hours
D. encourage the client to deep-breathe and cough every 2 hours |
|
Definition
B. administer oxygen by nasal cannula as prescribed.
When a pulmonary embolus places the client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the paO2 value of 60, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as prescribed. |
|
|
Term
The nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 bpm. His blood pressure is 80/50 mm Hg and he complains of dizziness. Which medication would be used to treat his bradycardia?
A. atropine
B. dobutamine (dobutrex)
C. amiodarone (cordarone)
D. lidocaine (xylocaine) |
|
Definition
A. atropine
IV push atropine is used to treat symptomatic bradycardia. |
|
|
Term
A client with COPD is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory rate, the nurse notes an abnormal inspiratory-expiratory ration of 1:4. What is a normal I:E ratio?
A. 1:2
B. 2:1
C. 1:1
D. 2:2 |
|
Definition
A. 1:2
The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. |
|
|
Term
The nurse is caring for a client who is recovering from an MI. The cardiologist refers him to cardiac rehab. Which statement by the client indicates an understanding of cardiac rehab?
A. "When I finish the rehab program I'll never have to worry about heart trouble again."
B. "I won't be able to job again even with rehab."
C. "Rehab will help me function as well as I physically can."
D. "I'll get rest during these rehab classes. All I have to do is sit and listen to the instructor." |
|
Definition
C. "Rehab will help me function as well as I physically can."
Cardiac rehab helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. |
|
|
Term
A client with COPD is recovering from an MI. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:
A. pleural effusion
B. pulmonary edema
C. atelectasis
D. oxygen toxicity |
|
Definition
C. atelectasis
In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction - a known cause of atelectasis. |
|
|
Term
A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?
A. administer IV fluids as ordered
B. administer a vasodilator as prescribed
C. insert an indwelling urinary catheter as ordered
D. instruct the client to sit up for several minutes before standing |
|
Definition
D. instruct the client to sit up for several minutes before standing
To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly to a standing position, such as by sitting up for several minutes first. |
|
|
Term
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?
A. decrease the heparin infusion rate
B. prepare to administer protamine sulfate
C. monitor the partial thromboplastin time (PTT)
D. start an IV infusion of dextrose 5% in water |
|
Definition
B. prepare to administer protamine sulfate
Frank hematuria indicates excessive anticoagulation and bleeding - and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. |
|
|
Term
Within hours after suffering a massive MI, a client experiences cardiogenic shock. All vital functions are being monitored closely; an intra-arterial catheter has been inserted to detect changes in arterial blood pressure. Which statement comparing intra-arterial and cuff blood pressure readings is accurate?
A. intra-arterial readings should be at least 10 mm Hg higher than cuff readings
B. intra-arterial readings should be at least 10 mm Hg lower than cuff readings
C. cuff readings are easier to obtain than intra-arterial readings
D. cuff readings detect excessive peripheral vasoconstriction more accurately than intra-arterial readings |
|
Definition
A. intra-arterial readings should be at least 10 mm Hg higher than cuff readings
Intra-arterial blood pressure readings should be at least 10 mm Hg higher than cuff readings |
|
|
Term
A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. skin rash
B. peripheral edema
C. dry cough
D. postural hypotension |
|
Definition
B. peripheral edema
Peripheral edema is a sign of fluid volume excess and worsening heart failure. |
|
|
Term
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
A. 15-60 secs
B. 5-20 mins
C. 30-40 mins
D. 45-60 mins |
|
Definition
B. 5-20 mins
Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. |
|
|
Term
A client with COPD and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
A. "weigh yourself daily and report a loss of 1 lb in 1 day"
B. "eat a high sodium diet"
C. "weigh yourself daily and report a gain of 2 lb in 1 day"
D. "maintain bed rest" |
|
Definition
C. "weigh yourself daily and report a gain of 2 lb in 1 day"
COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. |
|
|
Term
A client with COPD presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take?
A. notify the physician immediately so he can determine client competency
B. have the client sign a DNR form
C. determine whether the client's family was consulted about his decision
D. consult the palliative care group to direct care for the client |
|
Definition
A. notify the physician immediately so he can determine client competency
Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. Therefore, the physician should be notified immediately so he can determine client competency. |
|
|
Term
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?
A. consider this to be a normal finding for his age and race
B. recommend he have his BP rechecked in 1 year
C. recommend he have his BP rechecked within 2 weeks
D. recommend he see his physician immediately for further evaluation |
|
Definition
C. recommend he have his BP rechecked within 2 weeks
Although hypertension is more prevalent in the black population, a BP of 150/90 mm Hg isn't considered normal. He should have his BP rechecked within 2 weeks. |
|
|
Term
A client with severe angina and ST-segment elevation on the ECG is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:
A. creatine kinase level
B. hemoglobin level
C. troponin level
D. liver panel |
|
Definition
C. troponin level
Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during an MI. It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. |
|
|
Term
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
A. anxiety
B. imbalanced nutrition: more than body requirements
C. impaired swallowing
D. unilateral neglect |
|
Definition
A. anxiety
In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. |
|
|
Term
Which signs and symptoms are present with a diagnosis of pericarditis?
A. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
B. low urine output secondary to left ventricular dysfunction
C. lethargy, anorexia, and heart failure
D. pitting edema, chest discomfort, and nonspecific ST-segment elevation |
|
Definition
A. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. |
|
|
Term
| late signs of hypertension |
|
Definition
- retinal and other eye changes
- renal damage
- MI
- cardiac hypertrophy
- stroke |
|
|
Term
For patients with uncomplicated hypertension and no specific indications for another medication, what is the initial medication?
A. thiazide diuretic
B. calcium channel blockers
C. vasodilators
D. angiotensin converting enzyme inhibitors |
|
Definition
|
|
Term
|
Definition
- thiazide
- loop
- potassium sparing
- aldosterone receptor blockers |
|
|
Term
|
Definition
| BP > 180/120 and must be lowered immediately to prevent damage to target organs |
|
|
Term
|
Definition
| BP is very high but no evidence of immediate or progressive target organ damage |
|
|
Term
The nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client's blood pressure, which is 84/50 mm Hg. It's time for the nurse to administer the client's medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action is best taken by the nurse?
A. withhold the medications and notify the physician
B. administer the medications immediately
C. encourage the client to sit up and eat breakfast
D. administer the nitroglycerin and metoprolol and withhold the furosemide |
|
Definition
A. withhold the medications and notify the physician
The nurse should withhold the three medications and notify the physician. Each of these medications has the potential to lower the client's blood pressure. Administering them together when the client is already hypotensive may severely lower the client's blood pressure. |
|
|
Term
A client comes to the emergency department with status asthmaticus. His RR is 48, and he is wheezing. An ABG analysis reveals a pH of 7.52, a paCO2 of 30, paO2 of 70, and bicarb of 26. What disorder is indicated by these findings?
A. metabolic acidosis
B. respiratory acidosis
C. metabolic alkalosis
D. respiratory alkalosis |
|
Definition
D. respiratory alkalosis
Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in paCO2 to less than 35 mm Hg and an increase in blood pH over 7.45 |
|
|
Term
A client with Guillain-Barre syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of ABG values confirms respiratory acidosis?
A. pH 7.5, paCO2 30
B. pH 7.4, paCO2 35
C. pH 7.35, paCO2 40
D. pH 7.25, paCO2 50 |
|
Definition
D. pH 7.25, paCO2 50
In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbonda dioxide above 45 mm Hg. |
|
|
Term
The nurse suspects that a 68-year-old client has digitalis toxicity. The nurse should assess for:
A. hearing loss
B. vision changes
C. decreased urine output
D. gait instability |
|
Definition
B. vision changes
Vision changes, such as halos around objects, are signs of digitalis toxicity. |
|
|
Term
After receiving nitroglycerin (Nitrostat), a client verbalizes relief of chest pain. The physician prescribes transdermal nitroglycerin (Nitro-Dur), 5-mg patch daily, as prophylaxis for angina pectoris. When teaching the client how to apply the transdermal system, the nurse should provide which instruction?
A. "use the same clean, hairless application site each day."
B. "you may touch the medication pad after washing your hands"
C. "be sure to report skin irritation or other adverse reactions"
D. "store your supply of transdermal pads in the refrigerator" |
|
Definition
C. "be sure to report skin irritation or other adverse reactions"
This is the only correct instruction because transdermal nitroglycerin may cause skin irritation. |
|
|
Term
When a client is started on oral or IV diltiazem (Cardizem), the nurse should monitor for which potential complication?
A. flushing
B. heart failure
C. renal failure
D. hypertension |
|
Definition
B. heart failure
The chief adverse effects of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. |
|
|
Term
A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax? Select all that apply:
1. decreased cardiac output
2. flattened neck veins
3. tracheal deviation to the affected side
4. hypotension
5. tracheal deviation to the opposite side
6. bradypnea |
|
Definition
1, 4, 5
Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not allowing it to escape on expiration. The air presses against the mediastinum, causing a shift to the opposite side and decreased venous return (reflected by decreased cardiac output and hypotension). |
|
|
Term
The nurse is teaching a client who will be discharged soon with a prescription for warfarin (Coumadin). The nurse should include which statement in discharge teaching?
A. "increase your intake of yogurt and broccoli"
B. "this drug will dissolve any clots you may still have"
C. "if you miss a dose, double the next dose"
D. "avoid aspirin while taking warfarin" |
|
Definition
D. "avoid aspirin while taking warfarin"
Because aspirin decreases platelet agglutination and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects - and bleeding. |
|
|
Term
After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 325 mg PO daily. The nurse should teach the client that this medication has been prescribed to:
A. control headache pain
B. enhance the immune response
C. prevent intracranial bleeding
D. reduce the chance of blood clot formation |
|
Definition
D. reduce the chance of blood clot formation
TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, aspirin is prescribed to prevent clot formation by reducing platelet agglutination. |
|
|
Term
Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)?
A. "take an extra dose of digoxin if you miss one dose"
B. "call the physician if your heart rate is above 90"
C. "call the physician if your pulse drops below 80"
D. "take digoxin with meals" |
|
Definition
B. "call the physician if your heart rate is above 90"
The nurse should instruct the client to notify the physician if his heart rate is greater than 90 because cardiac arrhythmias may occur with digitalis toxicity. |
|
|
Term
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure
B. acute pulmonary edema
C. pneumonia
D. cardiogenic shock |
|
Definition
B. acute pulmonary edema
Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. |
|
|
Term
During digoxin (Lanoxin) therapy, the nurse should closely monitor the client's:
A. serum potassium and magnesium levels
B. urine glucose and ketones
C. serum potassium and creatine kinase levels
D. urine potassium and creatine kinase levels |
|
Definition
A. serum potassium and magnesium levels
During digoxin therapy, the nurse should closely monitor the client's serum potassium and magnesium levels. This is because hypokalemia or hypomagnesemia can predispose the client to digitalis toxicity. |
|
|
Term
A client is prescribed lisinopril (Zestril) for treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should teach him about which common adverse effects of ACE inhibitors? Select all that apply:
1. constipation
2. dizziness
3. headache
4. hyperglycemia
5. hypotension
6. impotence |
|
Definition
2, 3, 5
Dizziness, headache, and hypotension are all common adverse effects of lisinopril and other ACE inhibitors. |
|
|
Term
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?
A. call the physician
B. remove the malfunctioning cuff
C. add more air to the cuff
D. suction the client, withdraw residual air from the cuff, and reinflate it |
|
Definition
D. suction the client, withdraw residual air from the cuff, and reinflate it
After discovering an air leak, the nurse should first check for insufficient air in the cuff - the most common cause of a cuff air leak. to do this, the nurse should suction the client, withdraw all residual air in the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. |
|
|
Term
A client is in hemorrhagic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:
A. blood pressure
B. hemoglobin level
C. temperature
D. heart rate |
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Definition
A. blood pressure
With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. |
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Term
Before seeing a newly assigned client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
A. myasthenia gravis
B. type 1 diabetes mellitus
C. extreme anxiety
D. narcotic overdose |
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Definition
C. extreme anxiety
Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication |
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Term
| predisposing factors for respiratory alkalosis |
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Definition
- extreme anxiety
- fever
- heart failure
- injury to brain's respiratory center
- overventilation with mechanical ventilator
- pulmonary embolism
- early salicylate intoxication |
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Term
A client has a history of atrial fibrillation. To prevent a recurrence, the physician prescribes sustained-release procainamide hydrochloride (Procan SR), 500 mg PO every 6 hours. How soon after administering procainamide can the nurse expect the drug to reach its peak concentration?
A. 15 to 60 mins
B. 45 to 60 mins
C. 1.5 to 2 hours
D. 3 to 4 hours |
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Definition
C. 1.5 to 2 hours
Sustained-release procainamide preparations reach peak concentrations in 1.5 to 2 hours. |
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Term
A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?
A. assure the client that everything will be all right and that he shouldn't become upset
B. ask a family member to interpret what the client is trying to communicate
C. ask the physician to wean the client off the mechanical ventilator to allow the client to talk
D. ask the client to write, use a picture board, or spell words with an alphabet board |
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Definition
D. ask the client to write, use a picture board, or spell words with an alphabet board
If the client uses an alternative method of communication, he'll feel more in control and be less frustrated. |
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Term
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for carefully?
A. increase in blood pressure
B. increase in blood volume
C. low serum potassium level
D. high serum sodium level |
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Definition
C. low serum potassium level
Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. |
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Term
The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:
A. suctioning the tracheostomy tube frequently
B. using a cuffed tracheostomy tube
C. using the minimal air leak technique with cuff pressure less than 25 cm H2O
D. keeping the tracheostomy tube plugged |
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Definition
C. using the minimal air leak technique with cuff pressure less than 25 cm H2O
To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. |
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Term
A client with an acute MI is receiving nitroglycerin (Tridil) by continuous IV infusion. Which statement by the client indicates that this drug is producing its therapeutic effect?
A. "I have a bad headache"
B. "my chest pain is decreasing"
C. "i feel a tingling sensation around my mouth"
D. "my blood pressure must be up because my vision is blurred" |
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Definition
B. "my chest pain is decreasing"
Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium, thus producing its intended effect: relief of chest pain |
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Term
A client suffers ARDS as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
A. kinking of the ventilator tubing
B. a disconnected ventilator tube
C. an ET cuff leak
D. a change in the oxygen concentration without resetting the oxygen level alarm |
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Definition
A. kinking of the ventilator tubing
Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube |
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Term
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
A. initiate oxygen therapy
B. administer a heparin bolus and begin an infusion at 500 units/hour
C. administer analgesics as ordered
D. perform nasopharyngeal suctioning |
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Definition
A. initiate oxygen therapy
The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. |
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Term
A client on mechanical ventilation is receiving pancuronium bromide (Pavulon), IV as needed. Which assessment finding indicates that the client needs another pancuronium dose?
A. leg movement
B. finger movement
C. lip movement
D. fighting the ventilator |
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Definition
D. fighting the ventilator
Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so he breathes in synchrony with the ventilator. Fighting the ventilator is a sign that the client needs another pancuronium dose. |
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Term
In presenting a workshop on parameters of cardiac function, which conditions should the nurse list as those most likely to lead to a decrease in preload?
A. hemorrhage, sepsis, and anaphylaxis
B. MI, fluid overload, and diuresis
C. fluid overload, sepsis, and vasodilation
D. third spacing, heart failure, and diuresis |
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Definition
A. hemorrhage, sepsis, and anaphylaxis
Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating folume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. |
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Term
An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). to determine if the client has other major risk factors for CAD, the nurse should assess for:
A. a history of diabetes mellitus
B. elevated high-density lipoprotein (HDL) levels
C. a history of ischemic heart disease
D. alcoholism |
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Definition
A. a history of diabetes mellitus
Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. |
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Term
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
A. "clean the tracheostomy tube with alcohol and water"
B. "family members should continue to talk to the client"
C. "oral intake of fluids should be limited for 1 week only"
D. "limit the amount of protein in the diet" |
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Definition
B. "family members should continue to talk to the client"
Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. |
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Term
The home care nurse visits a client diagnosed with atrial fibrillation who is prescribed warfarin (Coumadin). The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?
A. "I will watch my gums for bleeding when I brush my teeth"
B. "I will use an electric razor to shave"
C. "I will eat four servings of fresh, dark green vegetables every day"
D. "I will report any unexplained or severe bruising to my doctor right away" |
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Definition
C. "I will eat four servings of fresh, dark green vegetables every day"
Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. |
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Term
The major cause of death after an MI is:
A. cardiogenic shock
B. cardiac arrhythmia
C. heart failure
D. pulmonary embolism |
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Definition
B. cardiac arrhythmia
Cardiac arrhythmias cause roughly 40% to 50% of deaths after MI. |
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Term
The nurse is awaiting the arrival of a client from the emergency department. The client has a left ventricular MI and is being admitted. In caring for this client, the nurse should be alert for which signs and symptoms of left-sided heart failure? Select all that apply:
1. jugular vein distention
2. hepatomegaly
3. dyspnea
4. crackles
5. tachycardia
6. right upper quadrant pain |
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Definition
3, 4, 5
Signs and symptoms of left-sided heart failure include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; fatigue; nonproductive cough and crackles; hemoptysis; point of maximal impulse displaced toward the left anterior axillary line; tachycardia and S3 and S4 heart sounds; and cool, pale skin. |
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Term
The nurse is evaluating a client who had an MI 7 days ago. Which outcome indicates that the client is responding favorably to therapy?
A. the client demonstrates the ability to tolerate increasing activity without chest pain.
B. the client exhibits a heart rate above 100 bpm
C. the client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking
D. the client states that sublingual nitroglycerin usually relieves chest pain |
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Definition
A. the client demonstrates the ability to tolerate increasing activity without chest pain.
The ability to tolerate increasing activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. |
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Term
What is the normal pH range for arterial blood?
A. 7 to 7.49
B. 7.35 to 7.45
C. 7.50 to 7.60
D. 7.55 to 7.65 |
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Definition
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Term
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
A. nausea or vomiting
B. abdominal pain or diarrhea
C. hallucinations or tinnitus
D. light-headedness or paresthesia |
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Definition
D. light-headedness or paresthesia
The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling of extremities). |
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Term
A competent client requiring long-term mechanical ventilation privately tells the nurse that she wants the ventilator withdrawn. Which response by the nurse is best?
A. "tell me how you are feeling?"
B. "what about your family?"
C. "you are asking us to do something we can't do."
D. "you have been doing so well." |
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Definition
A. "tell me how you are feeling?"
Option 1 uses an open-ended question that encourages the client to express her feelings. |
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Term
After receiving shift report, the RN in the cardiac step-down unit must prioritize her client care assignment. She has an ancillary staff member available to help her care for her clients. Which of these clients should the RN assess first?
A. the client with heart failure who is having some difficulty breathing
B. the anxious client who was diagnosed with an acute MI two days ago and who was transferred from the coronary care unit today
C. the demanding client who underwent coronary bypass surgery three days ago
D. the client admitted during the previous shift with new-onset controlled atrial fibrillation who has her call light on. |
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Definition
A. the client with heart failure who is having some difficulty breathing
The RN should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. |
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Term
A 47-year-old male client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:
A. lobar pneumonia
B. empyema
C. pneumocystic carinii pneumonia
D. infected chest tube wound site |
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Definition
B. empyema
Any condition that produces fluid accumulation of sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. |
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Term
A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?
A. the water level in the humidifier reservoir is too low
B. the oxygen tubing is pinched
C. the client has a nasal obstruction
D. the oxygen concentration is above 44% |
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Definition
B. the oxygen tubing is pinched
Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. |
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Term
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
A. complete the client's registration information, perform an ECG, gain IV access, and take vital signs
B. alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician
C. gain IV access, give sublingual nitroglycerin, and alert the cardiac catheterization team
D. administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin |
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Definition
D. administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin
Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. Ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. |
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Term
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes the highest priority at this time?
A. decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction
B. anxiety related to an actual threat to health status, invasive procedures, and pain
C. disabled family coping related to knowledge deficit and a temporary change in family dynamics
D. hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time |
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Definition
A. decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction
For a client recovering from CABG surgery, decreased cardiac output is the most important nursing diagnosis because myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased cardiac output. |
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Term
The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
A. inspection
B. chest x-ray
C. ABG levels
D. auscultation |
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Definition
D. auscultation
Breath sounds should be auscultated before doing postural drainage to determine the areas that need draining. |
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Term
Nursing assessment reveals that a client has paradoxical chest expansion. Such expansion is best described as:
A. a form of tachypnea
B. lung movement inward during expiration and outward during inspiration
C. a decreased respiratory rate
D. lung movement outward during expiration and inward during inspiration |
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Definition
D. lung movement outward during expiration and inward during inspiration
In paradoxical chest expansion, the lungs move outward during expiration and inward during inspiration. |
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Term
Considering a client's atrial fibrillation, the nurse must administer digoxin (Lanoxin) with caution because it:
A. affects the sympathetic division of the autonomic nervous system, decreasing vagal tone
B. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone
C. can induce hypertensive crisis by constricting arteries
D. can trigger proarrhythmia by increasing stroke volume |
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Definition
B. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone
The nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the AV node and junctional tissue, thus increasing the potential for new arrhythmias to develop. |
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Term
The nurse is evaluating the 12-lead ECG of a client experiencing an inferior wall MI. While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply:
1. notched T wave
2. presence of a U wave
3. T wave inversion
4. prolonged PR interval
5. ST segment elevation
6. pathologic Q wave |
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Definition
3, 4, 5
T wave inversion, ST segment elevation, and a pathologic Q wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T wave inversion. Injury results from prolonged ischemia and is reflected by ST segment elevation. Q waves may become evident when the injury progresses to infarction. |
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Term
A client receiving a lidocaine (Xylocaine) IV infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats, indicating heart failure. Which action can the nurse expect the physician to take first?
A. prescribing 100 mg of lidocaine PO every 6 hours
B. decreasing the lidocaine infusion to 1 mg/minute
C. increasing the lidocaine infusion to 3 mg/minute
D. discontinuing the lidocaine infusion |
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Definition
B. decreasing the lidocaine infusion to 1 mg/minute
In a client with heart failure or hepatic disease, the maintenance infusion of lidocaine should be reduced by one-third to one-half. Because the client is currently receiving 2 mg/minute, the physician will probably decrease the rate to 1 mg/minute. |
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Term
The nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the:
A. contralateral side in a simple pneumothorax
B. affected side in a hemothorax
C. affected side in a tension pneumothorax
D. contralateral side in a hemothorax |
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Definition
D. contralateral side in a hemothorax
The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. |
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Term
A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated? Select all that apply:
1. |
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Definition
3, 4, 5
Levels of CPK, troponin T,and troponin I elevate because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. |
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Term
A nurse is caring for a client who has a tracheostomy and temperature of 103 F. Which intervention will most likely lower the client's arterial blood oxygen saturation?
A. endotracheal suctioning
B. encouragement of coughing
C. use of a cooling blanket
D. incentive spirometry |
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Definition
A. endotracheal suctioning
Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation level. |
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Term
A client with masthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
A. check for an apical pulse
B. suction the client's artificial airway
C. increase the oxygen percentage
D. ventilate the client with a handheld mechanical ventilator |
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Definition
B. suction the client's artificial airway
A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. |
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Term
A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcome indicates that the client has adequate respiratory function?
A. the client exhibits orthopneic breathing
B. the client breathes at a rate of 16 to 20 breaths/min
C. the client uses accessory muscles to breathe
D. the client exhibits bilateral crackles on auscultation |
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Definition
B. the client breathes at a rate of 16 to 20 breaths/min
A respiratory rate of 16 to 20 breaths/min is a normal finding, indicating adequate respiratory function. |
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Term
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
A. pulmonary embolism
B. heart failure
C. cardiac tamponade
D. tension pneumothorax |
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Definition
B. heart failure
A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. |
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Term
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?
A. vital capacity
B. functional residual capacity
C. tidal volume
D. maximal voluntary ventilation |
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Definition
C. tidal volume
Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. |
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Term
A 33-year-old woman with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks her what treatments she is currently receiving for her disease. She is likely to mention which treatments? Select all that apply:
1. oxygen
2. aminoglycosides
3. diuretics
4. vasodilators
5. antihistamines
6. sulfonamides |
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Definition
1, 3, 4
Oxygen, diuretics, and vasodilators are among the common therapies used to treat pulmonary hypertension. Others include fluid restriction, digoxin, calcium-channel blockers, beta-adrenergic blockers, and bronchodilators. |
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Term
A client with end-stage chronic obstructive pulmonary disease requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?
A. the client will remain infection-free
B. the client will maintain adequate oxygenation
C. the client will maintain adequate urine output
D. the client will remain pain-free |
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Definition
B. the client will maintain adequate oxygenation
BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with chronic obstructive pulmonary disease who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. |
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Term
A client is admitted to the acute care facility for treatment of heart failure. The nurse expects the physician to prescribe which drug?
A. prednisone (Orasone)
B. hydroxychloroquine sulfate (Plaquenil Sulfate)
C. lidocaine (Xylocaine)
D. furosemide (Lasix) |
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Definition
D. furosemide (Lasix)
To maintain fluid balance - crucial for a client with heart failure - the physician typically prescribes a diruetic, such as furosemide; vasodilating agents; and drugs that increase contractility, such as digitalix glycosides. |
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Term
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority would be to assess her:
A. neuromuscular function
B. bowel sounds
C. respiratory rate
D. ECG results |
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Definition
D. ECG results
Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. |
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Term
Which measurement can best be used to monitor the respiratory status of a client with pulmonary edema?
A. ABG analysis
B. pulse oximetry
C. skin color assessment
D. lung sounds |
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Definition
A. ABG analysis
ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. |
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Term
A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?
A. the client with anorexia, weight loss, and night sweats
B. the client with crackles and fever who is complaining of pleuritic pain
C. the client who had difficulty sleeping, daytime fatigue, and morning headache
D. the client with petechiae over the chest who's complaining of anxiety and shortness of breath |
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Definition
D. the client with petechiae over the chest who's complaining of anxiety and shortness of breath
The client who is complaining of anxiety and shortness of breath and has petechiae over his chest should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. |
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Term
The nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs and symptoms in a client would suggest lidocaine toxicity?
A. nausea and vomiting
B. pupillary changes
C. confusion and restlessness
D. hypertension |
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Definition
C. confusion and restlessness
The nurse should observe for signs of lidocaine toxicity, such as confusion and restlessness. |
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Term
A client is prescribed hydralazine for blood pressure management. The nurse is teaching the client about hydralazine therapy. When should the client take his hydralazine?
A. upon arising in the morning
B. just before bedtime
C. on an empty stomach
D. with food |
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Definition
D. with food
oral hydralazine should be taken with food to promote absorption |
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Term
A 43-year-old man was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior MI. The nurse should anticipate which orders by the physician?
A. streptokinase, aspirin, and morphine sulfate administration
B. morphine administration, stress testing, and admission to the cardiac care unit
C. serial liver enzyme testing, telemetry, and a lidocaine infusion
D. sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry |
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Definition
D. sublingual nitroglycerin, tissue plasminogen activato
If 12 hours or fewer have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. |
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Term
Which treatment would be the best therapy for a stable client with digitalis toxicity?
A. activated charcoal
B. time and symptomatic treatment
C. hemodialysis
D. atropine |
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Definition
B. time and symptomatic treatment
Stable clients with digitalis toxicity are best treated with time while their kidneys excrete the metabolites and with the symptomatic treatment for the rhythm disturbances or nausea resulting from the toxicity. |
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Term
A client with suspected diagnosis of acute MI is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?
A. 30 mins to 1 hour
B. 2 to 3 hours
C. 4 to 6 hours
D. 12 to 18 hours |
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Definition
C. 4 to 6 hours
Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. |
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Term
To avoid a falsely elevated serum digoxin level, the nurse should wait how long after administering oral digoxin (Lanoxin) to draw a blood sample?
A. at least 1 hour
B. at least 4 hours
C. at least 6 hours
D. at least 8 hours |
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Definition
D. at least 8 hours
To avoid a falsely elevated serum digoxin level, the nurse should wait at least 8 hours after administering oral digoxin and at least 6 hours after administering IV digoxin to draw a blood sample. |
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Term
What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?
A. cardiac pacemaker
B. hypothermia-hyperthermia machine
C. defibrillator
D. intra-aortic balloon pump |
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Definition
D. intra-aortic balloon pump
Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. |
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Term
A client's x-ray reveals bilateral white-outs, indicating ARDS. This syndrome results from:
A. cardiogenic pulmonary edema
B. respiratory alkalosis
C. increased pulmonary capillary permeability
D. renal failure |
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Definition
C. increased pulmonary capillary permeability
ARDS results from increased pulmonary capillary premeability, which leads to noncardiogenic pulmonary edema. |
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Term
The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?
A. diaphragmatic breathing
B. use of accessory muscles
C. pursed-lip breathing
D. controlled breathing |
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Definition
B. use of accessory muscles
The use of accessory muscles for respiration indicates the client is having difficulty breathing. |
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Term
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
A. measuring and documenting the drainage in the collection chamber
B. maintaining continuous bubbling in the water-seal chamber
C. keeping the collection chamber at chest level
D. stripping the chest tube every hour |
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Definition
A. measuring and documenting the drainage in the collection chamber
The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). |
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Term
Which intervention would be most appropriate for a client with an ABG of pH 7.5, paCO2 26, O2sat 96%, bicarb 24, and paO2 94?
A. administer a prescribed decongestant
B. instruct the client to breathe into a paper bag
C. offer the client fluids frequently
D. administer prescribed supplemental oxygen |
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Definition
B. instruct the client to breathe into a paper bag
The ABG results reveal respiratory alkalosis. The best intervention to raise the paCO2 level would be to have the client breathe into a paper bag. |
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Term
A client has a heart rate of 170 bpm. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride (Xylocaine), an initial IV bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous IV infusion at 2 mg/min. The nurse can expect the client to begin experiencing an antiarrhythmic effect within:
A. 1 to 2 minutes after IV bolus administration
B. 1 to 2 minutes after continuous IV infusion
C. 10 to 15 minutes after IV bolus administration
D. 10 to 15 minutes after continuous IV infusion |
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Definition
A. 1 to 2 minutes after IV bolus administration
Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after IV bolus administration. |
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Term
The nurse just received shift report for a group of clients on the telemetry unit. which client should the nurse assess first?
A. the client with a history of atrial fibrillation
B. the client admitted with first-degree AV block whose cardiac monitor now reveals type II second-degree AV block
C. the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet
D. the client with a demand pacemaker whose monitor shows normal sinus rhythm at a rate of 90 bpm |
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Definition
B. the client admitted with first-degree AV block whose cardiac monitor now reveals type II second-degree AV block
The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). |
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Term
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by:
A. cerebral bleeding
B. I.M. injection
C. myocardial necrosis
D. skeletal muscle damage due to a recent fall |
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Definition
C. myocardial necrosis
An increase in CK-MB is related to myocardial necrosis. |
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Term
A client develops atrial fibrillation after an acute MI. The physician prescribes digoxin (Lanoxin), 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to:
A. an increased serum creatinine level
B. a decreased serum digoxin level
C. an increased serum creatine kinase (CK) level
D. a decreased serum CK level |
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Definition
C. an increased serum creatine kinase (CK) level
I.M. administration of digoxin isn't recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. |
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Term
When administering low doses of dopamine (Intropin), the nurse knows that dopamine activates which receptors?
A. alpha
B. beta 1
C. dopaminergic
D. beta 2 |
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Definition
C. dopaminergic
Dopamine activates dopaminergic receptor sites only at low doses. |
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Term
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
A. tracheal
B. fine crackles
C. coarse crackles
D. friction rubs |
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Definition
B. fine crackles
Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. |
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Term
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 bpm, a blood pressure of 162/90 mm Hg, and a temperature of 98.6 F. To help correct respiratory alkalosis, the nurse should:
A. insert a nasogastric tube (NG) as ordered
B. administer acetaminophen (Tylenol) as prescribed
C. instruct the client to breathe into a paper bag
D. administer antibiotics as prescribed |
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Definition
C. instruct the client to breathe into a paper bag
A client recovering from an acute asthma attack who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). |
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Term
Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
A. fluid intake for the past 24 hours
B. baseline ABG levels
C. prior outcomes of weaning
D. ECG results |
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Definition
B. baseline ABG levels
Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. |
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Term
A client with a history of an anterior wall MI is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observation for:
A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles |
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Definition
D. pulmonary crackles
High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. |
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Term
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which statement by the client most strongly suggests angina pectoris?
A. "The pain lasted about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain got worse when I took a deep breath."
D. "The pain occurred while I was mowing the lawn." |
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Definition
D. "The pain occurred while I was mowing the lawn."
Angina pectoris is chest pain cuased by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload; this, in turn, increases the heart's need for oxygen and may precipitate angina. |
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Term
A client has hypoxemia of pulmonary origin. What portion of ABG results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?
A. Partial pressure of arterial oxygen (PaO2)
B. partial pressure of arterial carbon dioxide (PaCO2)
C. pH
D. bicarbonate (HCO3) |
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Definition
A. Partial pressure of arterial oxygen (PaO2)
In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure (PEEP). |
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Term
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? Select all that apply:
1. decreased respiratory rate
2. dyspnea on exertion
3. barrel chest
4. shortened expiratory phase
5. clubbed fingers and toes
6. fever |
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Definition
2, 3, 5
Typical findings in clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. |
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Term
The nurse is performing a painless, noninvasive procedure to measure SaO2. What procedure is it?
A. incentive spirometry
B. ABG measurement
C. peak flow measurement
D. pulse oximetry |
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Definition
D. pulse oximetry
Pulse oximetry is a noninvasive procedure used to measure SaO2 in which a small sensor is positioned over a pulsating vascular bed. |
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Term
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
A. decreased renal blood flow causes the renin-angiotensin-aldosterone system to lower the secretion of aldosterone and antidiuretic hormone.
B. low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
C. decreased renal blood flow causes the renin-angiotensin-aldosterone system to raise aldosterone secretion.
D. low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation |
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Definition
B. low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster heart rate, vasoconstriction, and increased myocardial oxygen consumption. |
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Term
An 84-year-old male is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?
A. jugular vein distention
B. right upper quadrant pain
C. bibasilar fine crackles
D. dependent edema |
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Definition
C. bibasilar fine crackles
Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. |
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Term
A client in acute respiratory distress is brought to the emergency department. After endotracheal intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
A. they help prevent subcutaneous emphysema
B. they help prevent pneumothorax
C. they help prevent cardiac arrhythmias
D. they help prevent pulmonary edema |
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Definition
C. they help prevent cardiac arrhythmias
ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. |
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Term
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
A. cyanosis of the lips
B. bilateral crackles
C. productive cough
D. leg edema |
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Definition
D. leg edema
Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, neck vein distention, and hepatomegaly |
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Term
When administering dobutamine (Dobutrex), the nurse knows that its major clinical use is to:
A. increase cardiac output
B. prevent sinus bradycardia
C. treat hypotension
D. treat hypertension |
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Definition
A. increase cardiac output
Dobutamine increases cardiac out put for clients with acute heart failure and those undergoing cardipulmonary bypass surgery. |
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Term
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
A. poor peripheral perfusion
B. a possible hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure |
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Definition
B. a possible hematologic problem
SaO2 is the degree to which hemoglobin is saturated with oxygen. An individual with a subnormal Hb level could have normal SaO2 and still be short of breath. |
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Term
A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common symptom that typically resolves spontaneously?
A. depression
B. ankle edema
C. memory lapses
D. dizziness |
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Definition
A. depression
For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn't require medical intervention; however, family members should be aware that symptoms don't always resolve on their own. |
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Term
Following a coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II ECG strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex
B. widening complex
C. amplitude increase
D. amplitude decrease |
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Definition
D. amplitude decrease
Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. |
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Term
A client with severe angina and ST-segment elevation on the ECG is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:
A. creatine kinase level
B. hemoglobin level
C. troponin level
D. liver panel |
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Definition
C. troponin level
Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during an MI. |
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Term
The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
A. administer oxygen
B. have the client take deep breaths and cough
C. place the client in high Fowler's position
D. perform chest physiotherapy |
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Definition
C. place the client in high Fowler's position
The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. |
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Term
For a client with advanced COPD, which nursing action best promotes adequate gas exchange?
A. encouraging the client to drink three glasses of fluid daily
B. keeping the client in semi-Fowler's position
C. using a high-flow Venturi mask to deliver oxygen as prescribed
D. administering a sedative as prescribed |
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Definition
C. using a high-flow Venturi mask to deliver oxygen as prescribed
The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. |
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Term
During inspiration, which of the following occurs?
A. lungs recoil
B. diaphragm descends
C. alveolar pressure is positive
D. inspiratory muscles relax |
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Definition
B. diaphragm descends
During inspiration, inspiratory muscles contract, the diaphragm descends, alveolar pressure is negative, and air moves into the lungs. |
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