final exam 1 AH blue print

Purpose of a chest tube

Removes air, blood, or fluid so the lung can re-expand after pneumothorax, hemothorax, or surgery

Chest tube positioning rule

Keep system below chest level to prevent backflow

Why chest tubes should NOT be clamped routinely

Can cause tension pneumothorax

Water seal chamber — normal finding

Tidaling (normal rise and fall)

Water seal chamber — abnormal finding

Continuous bubbling = air leak

Emergency signs with a chest tube

Sudden dyspnea, tracheal deviation, absent breath sounds, hypotension (signs of tension pneumonthorax)

Atrial fibrillation rhythm characteristics

Irregular rhythm, no P waves

Biggest risk of atrial fibrillation

Stroke → needs anticoagulation

Hypokalemia EKG risk

Dysrhythmias

Hyperkalemia EKG sign

Peaked T waves

SVT characteristics

HR >150, no visible P waves

SVT priority treatment

Vagal maneuvers → Adenosine

V-tach WITH a pulse treatment

Wide QRS, fast → Synchronized cardioversion

Pulseless V-tach or V-fib treatment

No cardiac output → Defibrillate + CPR

PEA definition

Electrical activity present but no pulse

PEA treatment

CPR + epinephrine (NO shock)

Purpose of PA catheter

Hemodynamic monitoring in critically ill cardiac patients

What PA catheter monitors

Pulmonary artery pressures & cardiac output

Nursing responsibilities with PA catheter

Sterile care, waveform monitoring, watch for infection, dysrhythmias, air embolism

Who is always the priority patient?

Unstable patients (airway, breathing, circulation problems)

ABC

Priority symptoms

Acute chest pain, sudden SOB, new dysrhythmia, hypotension

Framework for triage decisions

ABCs + perfusion

Ventilator associated pneumonia VAP prevention — head of bed angle

Elevate 30–45°

Oral care for ventilated patients

Every 12 hours

Other VAP prevention measures

Proper suctioning, manage secretions, prevent condensation entering airway

Sedation vacation purpose for VAP

Assess readiness to wean from ventilator

Devices requiring strict sterile care

Central lines, PA catheters, chest tubes

Signs of infection to monitor

Fever, redness, drainage

Smoking major risk factors

CAD, AAA, pulmonary embolism

Smoking + oral contraceptives increases risk of

Clot formation

Warfarin nursing focus

Monitor INR, keep vitamin K intake consistent

Warfarin bleeding signs

Gums, urine, stool

Dabigatran med for DVT monitoring

No INR, but bleeding precautions still needed

Best position post-extubation

Semi-Fowler’s

Purpose of incentive spirometer

Prevents atelectasis

Daily weight reporting rule

2–3 lb/day or 5 lb/week gain

Diet education for advanced HF

Sodium and fluid restriction

Common HF symptoms to report

SOB, swelling, fatigue

Arm restriction after pacemaker insertion

Do not lift arm above shoulder on affected side

Pacemaker malfunction signs

Dizziness, syncope

Pacemaker ECG sign of capture

Pacemaker spike followed by QRS

Early AAA presentation

Often silent

Classic AAA findings

Pulsatile mass, bruit

Signs of ruptured AAA

Sudden back/abdominal pain + hypotension

Cullen’s(umbilical) & Turner’s (flank) signs indicate for AAA

Internal bleeding

Anxiety causes what acid-base imbalance

Respiratory alkalosis

What is ARDS

inf of lungs 7 days after infection

lungs suddenly get very inflamed and leaky, making it hard to get oxygen into the blood.

ARDS positioning benefit

Prone positioning improves gas exchange

Venous Thromboembolism VTE prevention methods

Early ambulation, leg exercises, compression devices

Aspirin purpose post-MI

Prevents platelet aggregation

Thrombolytic example & use

Alteplase (clot busing drug) dissolves clots in STEMI & PE

Loop diuretics used in HF

Furosemide, Bumetanide

Atropine use

Bradycardia (speed up heart)

Epinephrine use

Cardiac arrest

Amiodarone use

V-tach & V-fib (slow down heart)

Sodium bicarbonate use

Severe metabolic acidosis

Hypokalemia causes

Diuretics, vomiting

Hypokalemia signs

Weakness, dysrhythmias

Hypokalemia ECG changes

Flattened T waves, U waves

When to verify ET tube placement

After any movement

PE symptoms

Sudden dyspnea, chest pain, tachycardia

PE priority treatment

Oxygen, anticoagulation

ARDS causes

Sepsis, pneumonia, aspiration

ARDS key feature

Refractory hypoxemia, stiff lungs

ARDS treatment

Mechanical ventilation + prone positioning

Flail chest sign

Paradoxical chest movement

Beck’s triad (cardiac tamponade) consist of what S&S

Hypotension, JVD, muffled heart sounds

Cardiac tamponade treatment

Pericardiocentesis

Left Side HF

Crackles, dyspnea

Right side HF

Edema, JVD, ascites

Respiratory acidosis cause

Hypoventilation, ↑ CO₂

Metabolic acidosis causes

DKA, renal failure

Metabolic acidosis breathing pattern

Kussmaul respirations

What happens in DIC

Widespread clotting → bleeding

DIC lab findings

↑ PT/PTT, ↑ D- Dimer

↓ platelets, ↓ fibrinogen

ST depression or T‑wave inversion means

Ischemia (reversible ↓ oxygen to myocardium)

Elevated troponin indicates

Myocardial injury (NSTEMI or STEMI)

ST elevation in 2 contiguous leads means

STEMI → complete coronary occlusion → emergency PCI

STEMI priority action

Immediate cath lab (PCI)

Atypical MI symptoms occur in who

Women, older adults, diabetics

Atypical MI symptoms include

Fatigue, nausea, SOB, indigestion, weakness

First nursing actions for suspected Acute coronary syndrome ACS

12‑lead ECG ≤10 min, aspirin, O₂ if SpO₂ <90%, 2 IVs, cardiac monitor

Left‑sided HF causes congestion where

Lungs (pulmonary congestion)

Right‑sided HF causes congestion where

Body (systemic congestion)

Best indicator of fluid status in HF

Daily weights

BNP level means what

Elevated BNP = heart failure worsening

HF nursing priorities

High Fowler’s, oxygen, daily weights, Na⁺/fluid restriction

What is cardiac tamponade

Fluid compresses heart → ↓ ventricular filling → ↓ CO

Cardiac tamponade S&S

Beck’s triad
- Hypotension, JVD, muffled heart sounds

Pulsus paradoxus means

Drop in systolic BP during inspiration

Life‑saving treatment for tamponade

Pericardiocentesis

Biggest risk of atrial fibrillation

Stroke

VT WITH a pulse treatment

Synchronized cardioversion

VT WITHOUT a pulse treatment

Defibrillation + CPR

Ventricular fibrillation priority

Immediate defibrillation

Purpose of a pacemaker

Treat symptomatic bradycardia or heart blocks

Electrical capture means for pacemakers

Pacemaker spike followed by QRS

Failure to capture looks like for pacemaker

Spike with no QRS

Pacemaker post‑op teaching

Don’t lift arm above shoulder, report dizziness/syncope