Galen NSG 3130 Exam 4 Unit 9 & 10 (unfinished) with complete solutions

s/s of left-sided heart failure

restlessness, confusion, cyanosis, orthopnea, tachycardia, fatigue, pulmonary congestion, paroxysmal nocturnal dyspnea, elevated capillary wedge pressure

left ventricular failure or severe mitral stenosis

elevated capillary wedge pressure

pulmonary edema

tachycardia, increased cardiac workload, crackling in lower lobes (basilar crackles)

(on test, all options have to be correct, answer with basilar crackles is not correct because of the other options)

s/s of right-sided heart failure

fatigue, ascites, dependent edema, increased peripheral venous pressure, enlarged liver and spleen, distended jugular veins, weight gain, may be secondary to chronic pulmonary problems, anorexia, and complaints of GI distress

medications that are given for fluid overload

- bedrest in high fowlers positions, administer O2 as needed, slow IV rate to keep vein open, diuretics, and pain meds

- Lasix (furosemide), bumetanide, Demadex (torsemide), and Edecrin (ethacrynic acid) Thiazide diuretics, like Microzide (hydrochlorothiazide), chlorthalidone, and Zaroxolyn (metolazone)

EKG

detects cardiac arrythmias

chest x-ray

- can show multiple abnormalities

(pulmonary effusion, pneumothorax, pericarditis, pleural effusion, rib fractures, tumor, enlarged heart, atelectasis, pneumonia)

echocardiogram

- noninvasive ultrasound of the heart to detect the heart structure shape and function

- showing ejection flow of the heart

cardiac catheterization

- ejection flow with detected with MRI, while the DR inserts a catheter via the radial or femoral artery

- THIS IS AN INVASIVE PROCEDURE

- usually done outpatient can go home same day after monitoring

- biggest risk is bleeding

- if blockage is great, then they will place a stent

- if they find the blockage to be so severe, they will schedule for a sudden CABG

promote a healthy heart

- active lifestyle

- diet (no added salt to foods, limit fast food intake, no processed or frozen foods)

- stop smoking

- no alcohol

- maintain BP

- maintain normal sugar

- control cholesterol levels

understand steps to take if a cardiac monitor shows an arrythmia

identify heart healthy foods that can be recommended for a patient with poor perfusion

understand the medication warfarin and teaching necessary for this drug

- warfarin (coumadin) is a anticoagulant

- don't take vit K while taking this drug

- warfarin interferes with the synthesis of clotting factors

- all other anticoagulants inhibit the activity of clotting factors

know how to monitor a cardiac patient on a monitor that wants to ambulate

major risk factors for the development of cardiovascular disease-both modifiable, non-modifiable (traditional) and nontraditional risk factors

MODIFIABLE - smoking, obesity, diabetes, HTN, cholesterol/lipid levels.

NON-modifiable - sex, ethnicity, genetics, age.

atherosclerosis (book)

buildup of fatty plaques and is the primary contributor to cardiovascular disease

atherosclerosis (ppt)

- tends to increase with age and lifestyle

- most common cause of impaired blood flow to organs and tissues

- as vessels narrow and become obstructed, distal tissues receive less blood, oxygen, and nutrients

know what venous stasis is and how to prevent it/improve it

- venous stasis is inflammation of the skin in the lower legs due to chronic venous insufficiency

- this can be prevented by SCD and compression hose

- it is typically unilateral

know which lab results are expected when caring for a patient with a heart attack

understand what hemoglobin is, s/s of low hemoglobin and how it affects the body

sequential compression devices

SCD's reduce risk for lower extremity venous stasis and DVT/PE by gently massaging the leg by intermittently inflating

STOP sequential compression devices if...

if the patient complains of calf pain... then do tests to rule out DVT before putting them back on

s/s of DVT

- chest pain, shortness of breath, coughing, diaphoresis (sweating)

- immobility causes venous stasis by decreased blood flow

anti-embolism stockings are, what they prevent, and how they are used

- promote venous blood return and to prevent edema

- they are worn like socks and pull up to knees

know what can cause a stroke

- HTN

- obstruction of blood flow (tissue ischemia)

- traumatic injury to brain

know changes that can be made in the adult to reduce the risk of cardiovascular disease (maintain a healthy weight)

- eat a healthy diet

- get active

- maintain a normal blood sugar

- maintain a normal blood pressure

- don't smoke

- control cholesterol levels

labs that are drawn in association with cardiac issues, to include an MI

- cardiac enzymes:

- CK - creatine kinase (increased for heart attack)

- troponin - detects injury to heart muscles; levels increase 4-6 hrs after MI; peaking 10-24 hours after, but then residing to baseline

- LDL/HDL - cholesterol levels

- LDL is bad cholesterol; buildup of plaque can lead to atherosclerosis and heart disease

- HDL is good cholesterol; you want a healthy amount of this

troponin lab values in association with cardiac issues

detects injury to heart muscles; levels increase 4-6 hrs after MI; peaking 10-24 hours after, but then residing to baseline

s/s of hypoxia

cyanotic limbs, respirations shallow and lower, heart rate goes up, rapid pulse, clubbing, etc.

concerns with diuretics; what is person with HF is prescribed these

- concern with potassium

- worry about electrolytes

- do not eat rich vitamin K foods

- gums bleeding is not normalin any condition

patient has atrial fibrillation and they decide to come off of their warfarin (coumadin)... what could happen

a blood clot could form... then what could happen? STROKE

- if blood clot dislodged, it could go to the lungs or the brain, could cause a PE or stroke

nitroglycerin subq for MI

give nitro, wait 5 minutes, if nothin is resolved, then give another one... THEN give IV tPA (intravenous tissue-type plasminogen activator) within 3 hours of MI

patient is put on oxygen and stats rise to 91%, do you decrease the oxygen?

NO, we want the oxygen level above 95%, so 91% is not high enough

what does pulmonary edema look like outwardly?

accessory muscles used, discoloration or clubbing of fingernails, cyanosis, are they propped up in bed, not taking full breath in and out, etc.

(they would not get swelling of the feet – that is with heart failure)

what happens to cardiovascular system as we age?

arteries harden, could get blockages, more prevalence as we age (other factors can increase risk too, but age is unavoidable and increases risk in general)

pneumonia diagnostic tool

chest x-ray to see fluid build up and inflammation (how much air vs fluid)

the nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery... which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?

A. checking the patient’s right pedal pulse and warmth of the right leg - correct

B. checking pulse oximetry and listening to the patient’s lung sounds

C. checking bilateral radial pulses to check for a pulse deficit

D. estimating the patient’s jugular venous pressure

the nurse hears a loud murmur when listening to the patient's heart... which diagnostic test will best display the condition of the valves and structures within the patient's heart that could be causing the murmur?

A. chest x-ray

B. cardiac catheterization

C. echocardiogram - correct

D. electrocardiogram

the nurse is caring for a patient who has presented to the ER with chest pain... which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle?

A. chest x-ray

B. cardiac catheterization - correct

C. echocardiogram

D. electrocardiogram

the nurse finds the patient in cardiopulmonary arrest with no pulse or respirations... which oxygen delivery device will the nurse use for this patient?

A. non-rebreather mask

B. bag-valve-mask unit - correct

C. continuous positive airway pressure (CPAP)

D. high-flow nasal cannula

the nurse is caring for a patient who is hospitalized for pneumonia... which nursing diagnosis has the highest priority?

A. activity intolerance r/t generalized weakness and hypoxemia

B. impaired nutritional intake r/t poor appetite and increased metabolic needs

C. impaired airway clearance r/t thick secretions in trachea and bronchi - correct

D. lack of knowledge r/t use of nebulizer and inhaled bronchodilators

the nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented... what is the priority action of the nurse?

A. obtain an arterial blood gas to check for carbon dioxide retention - correct

B. increase the patient’s oxygen until the pulse oximetry is greater than 98%.

C. lower the head of the patient’s bed and insert a nasal airway.

D. administer a mild sedative and reorient the patient as needed.

the nurse is caring for a patient who has been prescribed warfarin (coumadin) therapy after being diagnosed with atrial fibrillation... the patient asks the nurse what could happen if the prescription doesn't get filled... what is the nurse's best response?

A. “you could have a stroke.” - correct

B. “your kidneys could fail.”

C. “you could develop heart failure.”

D. “you could go into respiratory failure.”

the nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg... which focused assessment question has the highest priority for this patient?

A. “do you have a headache or any dizziness?”

B. “do you have any chest pain or shortness of breath?” - correct

C. “when did you first notice the swelling and redness in your leg?”

D. “do you have any cramping or muscle spasms in your leg?”

incentive spirometer use

every 2 hours or as needed

(another question was 10 times in the hour)

possible causes for hypoxia

aspirated vomit, pulmonary fibrosis, high altitude, etc.

when a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (select all that apply.)

A. avoid going to crowded theaters and malls - correct

B. change catheters every 8 hours - correct

C. keep the home environment free of dust - correct

D. use bleach to clean suction equipment - correct

when assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration... this finding is documented as:

stridor

the nurse clarifies that the cough mechanism is stimulated when...

foreign substances are propelled by the cilia toward the respiratory tract

the nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is...

jaundiced

the nurse performing tracheotomy care will...

suction tracheotomy before beginning care

the nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should...

have the pharynx suctioned

a patient requires a precise concentration of 40% oxygen... which of the following devices would best allow for this?

A. a simple face mask

B. a nonrebreather mask

C. a partial rebreathing mask

D. a Venturi mask - correct

a nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between...

80 and 120mmHg

a patient has a history of chronic obstructive pulmonary disease (COPD)... the patient's oxygen flow rate should be set to no more than...

2 to 3 L/min

the nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in...

two deep breaths, then inhale deeply again and force out the air quickly

the nurse uses a diagram to show that when the diaphragm moves...

down, the negative pressure in the thoracic space pulls air into the lungs

when air collects in the pleural space

pneomothorax

hyperoxygenation can be done...

can be done with a manual resuscitation bag or through the ventilator and is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts

hyperinflation involves...

involves giving the clients breaths that are 1 to 1.5 times the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag.

procedure when a tracheostomy tube is dislodged

- priority is AIRWAY, replace the overture (?), insert the trach first... depending how long it's been dislodged, we would bag them to get hyperoxygenation, put non-rebreather mask

- put it back in, get them oxygenated, then listen to their lungs

normal changes of aging may contribute to problems of circulation in older adults, even when there is no actual pathology...

- decrease of muscle tone in the heart results in a decrease in cardiac output

- blood vessels become less elastic and have an increase in calcification

- impaired valve function in the heart is often the result of increased stiffness and calcification and results in a decrease in cardiac output

the nurse is teaching a client about methods to decrease the client's homocysteine level... what is correct to say?

- "homocysteine is an amino acid that may increase my risk for developing heart disease"

- "homocysteine levels may be decreased by taking a multivitamin with folate"

- "homocysteine levels may be decreased by taking a multivitamin with B6 and B12"

OXYGENNNNNN stuff

oxygen delivery by high-flow nasal cannula

- air is heated and humidified

- delivered by high-flow system

- delivery rate 15-40 L/min

- oxygen delivered from 60-90%

oxygen delivery devices fall into two categories

low-flow systems and high-flow systems

low-flow systems

simple nasal cannula, simple face mask, partial-rebreather mask and non-rebreather mask

high-flow systems

air-entertainment or Venturi mask and high-flow nasal cannula

oxygen delivery by simple nasal cannula

- encourage patient to breathe through the nose

- flow rates are as follows:

1 L/min - 24%

2 L/min - 28%

3 L/min - 32%

4 L/min - 36%

5 L/min - 40%

6 L/min - 44%

* do not administer oxygen through a simple nasal cannula greater than 6 L/min

* consider humidification at all levels, but especially flow rates of 4 L/min and higher

oxygen delivery by simple nasal cannula FLOW RATES

1 L/min - 24%

2 L/min - 28%

3 L/min - 32%

4 L/min - 36%

5 L/min - 40%

6 L/min - 44%

* do not administer oxygen through a simple nasal cannula greater than 6 L/min

* consider humidification at all levels, but especially flow rates of 4 L/min and higher

oxygen delivery by mask

- always humidify oxygen delivered by mask

- if there is a bad reservoir, ensure it is filled before placing mask on patient

- different kinds of masks

simple face mask

- no reservoir bag

- flowrates are as follows:

5 L/min - 40%

6 L/min - 45%

7 L/min - 50%

8 L/min - 55%

>8 L/min - 60%

partial rebreather mask

- flowrates and percent oxygenation values are 6-15 L/min and 70% - 90% respectively

- partial rebreather allows some of the exhaled air to enter the reservoir; the pt. re-breathes part of the exhaled air, which contained carbon dioxide and acts as a stimulus to breathe for some patients

why does the partial rebreather allow some of the exhaled air to enter the reservoir

the pt. re-breathes part of the exhaled air, which contained carbon dioxide and acts as a stimulus to breathe for some patients

non-rebreather mask

flow rates are 10-15 L/min and 60%-100% respectively

- special valves on the mark prevent room air from entering but allow exhaled air to leave the mask

Venturi mask

flowrates are 4 to 12 L/min and 24% to 60% respectively

- used to ensure accuracy of the oxygen concentration delivered; considered for use with carbon dioxide retaining patients

- color-coded dials; each color adaptor has a corresponding liter-per-minutes setting listed on it for the allowed perfect oxygen

- to change the perfect of oxygen being delivered, the adaptor must be changed inside of the tubing

tracheostomy mask and collar

- require special adaptation for oxygen administration

- oxygen is always humidified for tracheostomies

- flow rates and percent oxygenation values are similar to those for simple face mask

5 L/min - 40%

6 L/min - 45%

7 L/min - 50%

8 L/min - 55%

>8 L/min - 60%

hyperventilation - type of breathing?

Kussmaul's? rapid, deep, and labored

patient has paralysis, what is priority?

- aspiration risk ** trouble swallowing, worried about swallowing and aspiration - AIRWAY

- yes, you assess O2, inspirations and expirations.. yea, but what is priority ?? - AIRWAY (aspiration)

postural drainage with what types of patients

asthma, COPD, bronchitis, and pneumonia... it is for inflammation, congestion, sinus congestion (you don't want the mucus built-up)

what is postural drainage

the drainage by gravity of secretions from various lung segments

what is suctioning

suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction outlet

hyperinflation

involves giving the clients breaths that are 1 to 1.5 times the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag.

hyperoxygenation

can be done with a manual resuscitation bag or through the ventilator and is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts