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DMRN 129
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Find my PMI!
Tricuspid
9/28/2014
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence
followed by a Korotkoff sound. What action should the nurse take next?
A. Note the presence of an auscultatory gap
B. Reinflate the cuff to a higher number
C. Reposition the stethoscope over the brachial artery
D. Continue with the blood pressure assessment<
But if the nurse immediately hears a Korotkoff sound: what she needs to do?
And if the patient is elderly and the nurse suspects an auscultatory gap?
During a fecal impaction removal, and elderly male client complains of feeling dizzy and
cold. What intervention should the nurse implement?
A. Insert a gloved finger into the rectum and gently massage the rectal sphincter to
facilitate relaxation
B. Encourage the client to take slow, deep breaths while continuing the procedure
C. Instruct the UAP to apply a warm blanket and massage the clients back
D. Stop the procedure and observe for a reduction in symptoms before continuing<
Before a Foley insertion or giving a bed bath, which condition is the most important to
consider in a patient?
A. Iodine allergy
B. Infected skin wound
C. Orthopnea<
D. Left sided hemiplegia
FROTHY SPUTUM
CVP?
CRACKLES
Cor Pulmonale?
PCWP?
AFTERLOAD: BP
Cardiac Output???
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Dependent edema
Ascitis, bloating
Cough (nocturnal)
Weight gain
Fatigue, confusion
Fatigue, confusion
S3 gallop: 1,2,3
Decreased renal function
SWAN-GANZ CATHETER
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A.
B.
C.
D.
Tetralogy of Fallot
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Squatting / Knee-Chest
Why?
What to do?
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Hypertension in upper
extremities.
Absent pulses in lower
extremities
Ankle/brachial index < 0.9
Difference UE/LE BP > 20
mmHg
Complication: Heart failure
The nurse is caring for a toddler who has a medical diagnosis of coarctation of
the aorta. Which assessment finding should the nurse report to the healthcare
provider immediately?
A. Pulse oximeter reading of 94%
B. Crackles at the end of inspiration<
C. Weak femoral pulses
D. Blood pressure higher in upper extremities
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ASO +
Rest, ASA.
Prophylactic antibiotics for R.F.
Life long prophylactic antibiotics for
bacterial endocarditis
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Valvular vegetations
Septic Embolus to circulation
Symptoms:
Fever, new onset murmurs,
sepsis, embolizations, ESR
Diagnostic: echocardiogram, blood
cultures
Treatment: antibiotics for 6 weeks.
Prophylaxis of endocarditis
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The nurse is assessing a client with bacterial meningitis. Which assessment finding
indicates the client may have developed septic emboli?
A. Cyanosis of the fingertips.<
B. Bradycardia and bradypnea.
C. Presence of S3 and S4 heart sounds.
D. 3+ pitting edema of the lower extremities.
Aspirin
A child presenting fever and joint pain is diagnosed with rheumatic fever.
What is the primary goal of nursing care?
A. Maintain fluid and electrolyte balance
B. Maintain joint mobility and function
C. Reduce fever
D. Prevent cardiac damage<
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Inflammation of pericardium:
Cardiac Tamponade
Pericardiocentesis
AUSCULTATION:
PERICARDIAL RUB
PERICARDIAL EFUSION: MUFFLED HEART SOUNDS
PERICARDIAL EFUSION UNDER TENSION: CARDIAC TAMPONADE
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SHOCK
PATHOLOGY
EXAMPLES
TREATMENT
HYPOVOLEMIC
Hemorrhage
Dehydration
Fluids: NS, LR
Blood
CARDIOGENIC
Pump failure
(Left ventricle fails)
MI, myocarditis
Oxygen
Nitroprusside
Dobutamine
DISTRIBUTIVE
Sympathetic tone.
Vasodilation
Neurogenic:
spinal shock
SVR
Cardiac output
Vasogenic:
Anaphylaxis
Sepsis (SIRS)
Vasopressors:
Epinephrine
Dopamine
Fluids
Plasma, albumin
Antibiotics
Blood flow
obstruction
P. Embolism
C. Tamponade
T. Pneumothorax
Thrombolysis
Pericardiocentesis
Chest tube
Microcirculation
Cell hypoxia
Lactic acidosis
Oliguria
(hyperdynamic)
OBSTRUCTIVE
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The ER is alerted that a child is arriving with a history of flu like symptoms for
the past week. The vital signs are T 102 oF, HR 168 bpm, RR 16 bpm, and BP
90/60 mmHg. The child is lethargic with a capillary refill of 4 seconds. What
equipment should be ready?
A. Automated defibrillator
B. Mechanical ventilator
C. IV infusion pump<
D. Cooling blanket
A patient is admitted with vomits and diarrhea. BP 60/0 mmHg, HR 140 x, RR:
28 rpm Urinary output 10 ml/hr, Specific gravity 1.043, Capillary refill 4
seconds. The nurse anticipates an order of:
A. NS (0.45%) IV at a rate of 150 ml/hr
B. LR at a rate of 25 ml/hr
C. NS at a rate of 130 ml/hr<
D. Sodium Nitroprusside IV at 3 mcg/Kg/min
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Contractility
Inotropism?
Heart rate
Chronotropism?
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Diagnostic studies
Treatment:
Tolerance phenomenon
Viagra interaction
Storage of nitrates
Normal EKG
ST depression26
ECG: ST depression
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Treatment:
Reperfusion arrhythmia
Risk for hemorrhages
ASA/Clopidogrel
Beta blockers or CCB
ACE inhibitors
Surgical:
MI
PTCA
Stent
CABG
Complications:
Heart failure
Rupture of papillary muscle
Pericarditis
Ventricular dysrhythmias: PVC VT VF
Cardiac Arrest
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ST Elevation: Acute MI
Pathologic Q wave: Old MI
NSTE MI: Enzymes
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Rehabilitation:
Stop if SBP drops more 10 mmHg
Stop if heart rate increases more 20 bpm
Consult physician
Usually authorized when able to climb 2 flights of stairs without symptoms
Can take nitro prophylactically before sex
Nitroglycerin:
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Written consent
Assess history of allergies
NPO (sip of water for meds is OK)
Explain
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EKG?
What means?
PR > O.20 sec
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Rate:
120 bpm
Rate:
58 bpm
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Interventions:
Anticoagulant
Diltiazem, beta-blocker, digoxin if frequency is too high
Synchronized cardioversion
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ATRIAL FIBRILLATION
ATRIAL FLUTTER
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R on T phenomenon
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Sensing:
patients QRS
Capture:
Compare to normal
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Airway
Use head tiltchin lift; if suspected neck injury present, use jaw thrust
ACLS:
Pregnancy:
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Arrhythmia Dance
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Immediately after the nurse delivers and unsynchronized shock for a pulseless
chaotic rhythm, the clients cardiac monitor shows an organized electrical
rhythm. Which intervention should the nurse implement first?
A. Palpate for a carotid pulse
B. Administer an antiarrhythmic
C. Assess for a blood pressure
D. Perform CPR for two minutes<
The nurse is reviewing a clients electrocardiogram and determines that the PR
interval is prolonged. What does this finding indicate?
A. Increased conduction time from the SA node to the AV junction<
B. Inability of the SA node to initiate an impulse at the normal rate
C. Initiation of the impulse from a location outside the SA node
D. Interference with the conduction through on or both ventricles
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Peripheral Vascular
Disease:
Venous Disease
Arterial Disease
History:
Varicose veins,
DVT
Intermittent Claudication,
DM, Tobacco
Elevation
Hanging down
Capillary Refill:
< 3 seconds
> 3 seconds
Normal: >1
Abnormal: < 1
Skin:
Pigmented (hemosiderin),
Normal pulses,
Varicose veins and edema
Ulcer Localization:
Above malleolus, on
medial malleolus
Ulcer Aspect:
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Buergers Disease?
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Etiology:
Idiopathic
Chronic trauma
Connective tissue disease (SE)
Treatment:
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Immediate postoperative nursing care for a client who has had a surgical repair of an
abdominal aortic aneurysm should include which interventions?
a. Assessing pedal pulses frequently and monitoring the nasogastric drainage.<
b. Maintaining strict bed rest for 72 hours and assessing radial pulses.
c. Monitoring an infusion of IV heparin and checking the PTT level daily.
d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter.
What is the most important intervention in peripheral artery disease management?
a. Elevate the legs at night while in bed
b. Rest to avoid intermittent claudication pain
c. Quit smoking<
d. Take a daily dose of pediatric aspirin
Client with diagnosis of AAA complains of back pain radiated to left inguinal area.
Which assessment is a priority?
a. Arterial blood gases and urinalysis
b. Palpation of abdomen for pulsating masses
c. Blood pressure and hematocrit<
d. Abdominal auscultation for bruits
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From: An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart
Association, the American College of Cardiology, and the Centers for Disease Control and Prevention
J Am Coll Cardiol. 2014;63(12):1230-1238. doi:10.1016/j.jacc.2013.11.007
Figure Legend:
Appendix
Date of download:
8/22/2014
Used to treat
Hypertension
Heart failure
Diabetic nephropathy
Side effects
Persistent dry cough
Orthostatic hypotension: avoid hot showers
Hyperkalemia
Teratogenic
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Heparin sodium
Interventions
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Diuretics
Thiazides: HCTZ
Loop diuretics: furosemide, butenamide
Potassium sparing diuretics:
Spironolactone (Aldactone), Triamterene, Amiloride
Antidysrhythmic Medications
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Syncope
Angina
Dyspnea
Reassure
Oxygen
Aspirin
Bed rest
Oxygen
Opiate
Monitor
Anticoagulate
Dressler's syndrome
Lidocaine
Arrhythmia/ Anemia
Ischemia/ Infarction/ Infection
Beta blocker
Angioplasty
Forgot medication
Morphine
IV access
Narcotic analgesics (eg morphine, pethidine)
Facilities for defibrillation (DF)
Aspirin/ Anticoagulant (heparin)
Rest
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DMRN 129
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Adventitious sounds
Crackle or rale: Mainly at end of inspiration, not cleared by
coughing: pneumonia (unilateral) or pulmonary edema (bilateral)
Wheeze: Musical, sibilant, predominate in expiration
Rhonchi: Low pitched, gargling, clear with cough or suction
Pleural friction rub: Grating quality, stop if apnea. Pleuritic pain
Stridor: High pitched, lauder in neck than in chest
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Epiglottitis
Interventions
Laryngotracheobronchitis (LTB)
Interventions:
A client develop skin rash, shortness of breath and wheezes after receiving a
dose of ceftriazone (Rocephin). The nurse needs to be prepared to administer
the ordered:
A. Diphenhydramine (Benadryl) 25 mg PO
B. Hydrocortisone 100 mg IV stat
C. Albuterol 2.5 mg via nebulization
D. Epinephrine 1:10000: 0.1 mg IV every 3-5 minutes<
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Postoperative interventions
Tonsillectomy Scab
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Inflammation + bronchoconstriction
Increased eosinophil count
Decreased FEV1 and peak expiratory flow
Status asthmaticus
Pulsus paradoxus
abolition of wheezes
Medications
Rescue: Short-acting 2 agonists: albuterol & metaproterenol (Alupent)
Side effects: Tachycardia, palpitations, tremor and hyperglycemia
Long term management:
Corticosteroids: fluticasone (Flovent), budesonide (Pulmicort)
Thrush. Growth retardation. Immunsupression .
MDI technique
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A.
B.
C.
D.
A 6 year old who has asthma is showing a prolonged expiratory phase and
wheezing, and has a 35% of personal best peak expiratory flow rate. What
action should the nurse take first?
A.
B.
C.
D.
A.
B.
C.
D.
A client with pneumonia has arterial blood gases at: pH 7.33, PaCO2 49 mmHg,
HCO3 25 mEq/L, PaO2 95 mmHg. What intervention should the nurse
implement?
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Chronic Bronchitis
Emphysema
Smoking cessation
Pursed lip respiration
Low flow O2
Bronchodilators: anticholinergics
Vaccines: pneumococcal, flu
Nutrition:
Low carbohydrates: why?
High calories and proteins
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95
The nurse is assessing a client who smokes cigarettes and has been
diagnosed with emphysema. Which finding should the nurse expect this
client to exhibit?
A.
B.
C.
D.
<
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Symptoms
Sudden collapse (1st to 2nd week post-surgery, long travels, after childbirth)
Hypotension
Hypoxemia and SOB
Neck vein distension, increased CVP and PCWP
Chest pain: lateral chest, increase with respiratory movements
Hemoptysis: rare
Spiral CT angio-scan
V/Q scan
Arteriography
D-dimer
Diagnostic
Treatment:
Thrombolytic therapy
Anticoagulants
Vena Cava Filter
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V-Q SCAN
Two days postoperative, a male client reports aching pain in his left leg.
The nurse assesses redness and warmth on the lower left calf. What
intervention should be most helpful to this client?
A. Apply sequential compression devices (SCDs) bilaterally.
B. Assess for a positive Homan's sign in each leg.
C. Pad all bony prominences on the affected leg.
D. Advise the client to remain in bed and compare legs circumferences<
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Management:
Fluid restriction
Oxygen
Artificial ventilation and PEEP
Prone position
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Figure 2: Computed tomography scan of the lungs showing acute respiratory distress
syndrome when the patient is lying supine (left) and prone (right).
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NO SUPINE: ASPIRATION
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Diagnose:
Treatment
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10
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Symptoms
TB drugs : Quimoprophylaxis Vs. Treatment
Isoniazid (INH)
Rifampin
RESPIration
Rifampicin: Hepatotoxic
Ethambutol: Optic neuritis
Streptomycin: Oto-nephrotoxic
Pyrazinamide: Hepatotoxic
Isoniazid: hepatotoxic, neuropathy
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Flail chest
Mechanical Ventilation
Causes of alarms
High pressure: Increased secretions; wheezing; bronchospasm; kinks in
tubing; client bites endotracheal tube
Low pressure: Disconnection or leak in ventilator or clients airway cuff;
client stops spontaneous breathing
Complications
Hypotension
Pneumothorax
Stress ulcers
Infections
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Description
Collection chamber
Water-seal chamber
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Nursing interventions
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Oxygen therapy:
FiO2 50-75%
Reservoir bag to be kept semi-inflated in
inspiration
No valves: dead space air is rebreathed
FiO2: 80-100%
Same management of reservoir bag
Unidirectional valve in reservoir bag: open in
inspiration, close in expiration
Flaps over lateral ports: open in expiration,
close in inspiration
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Dislodgement:
Tracheomalacia/stenosis
Tracheal-esophageal fistula:
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The alarm of a clients pulse oxymeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first?
Administer oxygen by face mask. <
Provide 100 % oxygen by nasal cannula
Prepare patient for endotracheal intubation
Repeat the O2 sat measurement in 10 minutes
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Glaucoma:
Macular degeneration:
Dry (atrophic, age related) or wet (exudative, more severe)
Loss of central vision
Cataracts:
Risk factors: age, DM, steroids, UV light, tobacco, alcohol.
Loss of red reflex (milky white pupil), blurred vision, diplopia
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Glaucoma
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Canal of
Schlemm
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Retina detachment:
Contusions
Penetrating objects
Chemical burns
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Sli
de
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12
7
128
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In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an intraocular pressure (IOP) of 28 mmHg. What
information should the nurse ask the client?
A. Length of time the client has been wearing prescription lenses.
B. Recent experience of seeing light flashes or floaters.
C. Complaints of any blind spots in the client's field of vision.
D. Use of prescribed eye drops since last exam by ophthalmologis<
Before administering timolol maleate (Timoptic) to a client with open-angled
glaucoma, which finding should the nurse report to the healthcare provider?
A. Has a family history of diabetes mellitus, type I.
B. Receives carvedilol (Coreg) for heart failure (HF). <
C. Works outdoors as a construction site supervisor.
D. Drinks a cup of alcoholic beverages daily.
During the admission assessment, the nurse identifies that the client's upper
eyelids are drooping. Which term should the nurse document to describe this
assessment finding?
A. Ptosis. <
B. Bells palsy.
C. Blefaritis.
D. Myasthenia Gravis.
129
Slide 14-130
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Normal tone of voice, face audient, longer phrases better than short, care consonants sounds,
dont drop the volume at the end of sentence, pantomime and write
Otitis Media
Position: lateral with affected ear down
Myringotomy
Insertion of tympanostomy tubes
Keeps ear dry: earplugs when showering, diving not allowed
Avoid straws, blowing nose one each time for 7-10 days
Menieres disease
Vertigo + tinnitus + fullness + neurosensorial hearing loss: recurrent
Safety. Change of position
Low sodium diet. Diuretics. Antivert.
Otosclerosis:
Hereditary ossification around stapes, more common white females
Post stapedectomy care: anticipate vertigo, avoid swimming and pressure
changes (cough, sneeze, use of straw)
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External Otitis:
Risk factors:
Swimming
Topical antibiotics
Motion Sickness:
Scopolamine patch
4 hours before
travel
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AC & BC lost in
the same proportion:
AC>BC
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CONDUCTIVE
SENSORINEURAL
WEBER
Lateralization to
bad ear
Lateralization to
good ear
RINNE
Negative,
BC>AC
Positive, AC>BC
(but reduced 3:1)
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