Diagnostic Tests and Treatments for Acute Coronary Syndrome, Exams of Nursing

Download Diagnostic Tests and Treatments for Acute Coronary Syndrome and more Exams Nursing in PDF only on Docsity! Critical Care Exam 1 Questions and Answers. When administering nitroglycerin, which possible outcome does the nurse need to monitor the patient for? A. Peripheral vasoconstriction with tissue necrosis B. Increased afterload C. Peripheral vasodilation D. Increased preload - Correct Answers C. peripheral vasodilation A patient is admitted to the ICU with a pulmonary artery (PA) catheter in the left internal jugular. During the nurse's shift, the PA pressure increases. What additional priority assessment does the nurse need to perform next? A. Assess the patient's urine output B. Assess the patient's lung sounds C. Assess the patient's blood pressure D. Assess the patient's heart rhythm - Correct Answers B. Assess the patient's lung sounds The nurse is caring for a patient with an internal jugular central line and a left radial arterial line. The patient asks the nurse why he needs two lines and what the difference is. What will the nurse include in the explanation? A. "The internal jugular line is only for medication administration and the arterial line monitors your central venous pressure." B. "The internal jugular line is for monitoring your central venous pressure and the arterial line is only for medication administration." C. "The internal jugular line is only for monitoring your central venous pressure and the arterial line is for monitoring your blood pressure." D. "The internal jugular line is for monitoring your central venous pressure and medication administration. The arterial line is for monitoring your blood pressure." - Correct Answers D. "The internal jugular line is for monitoring your central venous pressure and medication administration. The arterial line is for monitoring your blood pressure." The nurse observes asystole on the patient's telemetry monitor. What is the nurse first action? A. Carry out defibrillation. B. Notify the physician. C. Assess the patient. D. Administer atropine IV. - Correct Answers C. Assess the patient. When reviewing the patient's medication administration record (MAR) the notes the medication atropine listed. The nurse understands that this medication is administered for which problem? A. Symptomatic bradycardia B. Symptomatic tachycardia C. Supraventricular tachycardia D. Ventricular dysthymias - Correct Answers A. Symptomatic bradycardia A patient has an intraaortic balloon pump (IABP) in the left groin. Which assessment finding requires immediate action by the nurse? A. Heart rate of 60 beats per minute B. New onset confusion C. Blood pressure of 90/55 D. Scant amount of blood on the left groin dressing - Correct Answers B. New onset confusion The nurse is caring for a patient with a congestive heart failure and a central venous pressure (CVP) of 15.. The nurse administers 40mg Lasix IVP as per physician order. What will the nurse monitor to evaluate the effectiveness of the treatment? A. Assess the patient's skin turgor. B. Patient reports feeling "better." C. Central venous pressure increases to 20. D. Central venous pressure decreases to 8. - Correct Answers D. Central venous pressure decreases to 8. A patient who had an actue myocardial infarction 12 hours ago has hemodynamic monitoring. While monitoring the patient, the nurse notes the Sinus Bradycardia Symptoms - Correct Answers dizzy, weakness, decreased BP, confusion, dyspnea, diaphoresis, syncope Sinus Bradycardia Treatment - Correct Answers Atropine: 0.5 mg IV bolus (least invasive first) D-Fib Pads on pacing mode Treat Causes: hypoxia, hypothermia, ischemia, e-imbalance, drug toxicity Sinus Tachycardia - Correct Answers HR: > 100 P-Wave: 1 P for every QRS, all same shape PR Interval: 0.12-0.20 sec QRS Complex: all the same shape <0.12 Sinus Tachycardia Causes - Correct Answers fever, anemia, hypotension, pulmonary embolissm, and myocardial infarction Sinus Tachycardia Treatment - Correct Answers Beta Blockers Calcium Chanel Blockers = control/slow HR Treat underlying causes = if anemia give RBC and IV fluid Atrial Fibrillation - Correct Answers Drugs: Diltiazem, Cardizem, Digoxin Vagal Maneuver Cardioversion = DONT if clot Need anticoagulant NO P WAVES Atrial Flutter - Correct Answers F Waves = sawtooth pattern P Waves before QRS = can predict Ventricular Tachycardia - Correct Answers a very rapid heartbeat that begins within the ventricles VT with a Pulse - Correct Answers assess patient, give medications (cardioversion) cardiovert early vagal maneuvers Amidarone 300 mg bolus than 150 mg drip "VTach and awake meds I must take" VT without a pulse - Correct Answers CPR Epinephrine = 1 mg every 3-5 mins DFIB = continuous and not just on R wave "Vtach and nap, ZAP ZAP ZAP" Amiordarone 300 mg bolus, then 150 mg drip Ventricular Fibrillation - Correct Answers NEVER has a pulse CPR Epinephrine = 1 mg every 3-5 mins DFIB = continuous and not just on R wave "Vtach and nap, ZAP ZAP ZAP" Amiordarone 300 mg bolus, then 150 mg drip IMMEDIATE DFIB SHOCK - CPR for 2 min - Shock - CPR for 2 min - EPI 1 mg every 3-5 min - Shock - CPR 2 min - Amiodarone 300 mg Asystole - Correct Answers DO NOT SHOCK - EPI 1 mg every 3-5 min "every dead man gets epi!" Fix H & T's - Hypovolemia, hypoxia, hyrogen ions (acidosis), hypo/hyperkalemia, hypothermia - Tension pneumothorax, cardiac tamponade, toxins, pulmonary thrombosis, coronary thrombosis Pulseless Electrical Activity - Correct Answers ensure if there is a pulse or it would be classified as this MAY LOOK like normal sinus Cardiac Dysrhythmias Interventions - Correct Answers - Appropriate cardiac monitors - Give medication - Document - Prepare for ACL's ABC (airway always first) The nurse is caring for a patient with angina who suddenly develops sharp substernal chest pain. The nurse notes that the patient is hypotensive and diaphoretic. What is the priority action of the nurse? A. Place the patient in a knee-chest position B. Administer asprin 325 mg PO C. Obtain an immediate EKG D. Administer morphine 4 mg IV as ordered by the physician - Correct Answers C. Obtain an immediate EKG The nurse correlates which assessment finding in the patient with left sided heart failure post MI? A. Decreased cardiac ouput B. increased pulmonary artery pressure C. Bilateral crackles upon ausculation of the lungs bases bilaterally. D. All of the above - Correct Answers D. All of the above The nurse is caring for a patient in a small rural hospital who has been admitted with an acute myocardial infarction. The patient is receiving a tPA infusion and is becoming increasing difficult to arose. What is the nest best nursing action? A. Notify the healthcare provider B. NO action is required, this is normal response to tPA C. Perform a neurological assessment D. Obtain an ECG and cardiac enzymes - Correct Answers C. Perform a neurological assessment A physician orders tPA on a patient with ST segment elevation. What information in the patient's assessment should the nurse report to the physician before starting tPA? A. Concussion 6 months ago - SVO2 Placement: through the SC, internal or external jugular, of femoral veins Pulmonary Artery Pressure - Correct Answers reflects the blood pressure in the pulmonary artery - generated by right ventricular ejecting blood into the pulmonary circulation *gives right arterial pressure, pulmonary artery pressure, and pulmonary wedge pressure" LOW pulmonary artery pressure - Correct Answers decreased preload in the PA catheter Wedge Pressure - Correct Answers left ventricular diastolic pressure - reflect left heart preload - obtained when the balloon located at the end of the Pulmonary Artery is inflated INCREASED preload results in - Correct Answers increased cardiac output Cardiac Output - Correct Answers The volume of blood ejected from heart in one minute. - dependent on stroke volume = volume of blood pumped from the left ventricle with each heartbeat HR X SV Pulmonary Artery Catheter Monitoring - Correct Answers evaluate SvO2 levels (mixed venous) = measures the adequacy of tissue oxygenation Normal: 60-80% High: too much increased oxygen supply or too much decreased oxygen demand Low: low hemoglobin, SaO2, CO or increased oxygen demand Assess for risk of infection and bleeding Low pulmonary artery pressure - Correct Answers give a fluid bolus to decrease preload NEED VOLUME Arterial Line - Correct Answers constant monitoring of systemic blood pressure - gives ABG reading Placement: radial, femoral, brachial **CANT PUT ANYTHING IN THIS LINE** Femoral placement of hemodynamic monitoring - Correct Answers must be on bed rest HOB = below 30 degrees Arterial Line on monitor - Correct Answers dicrotic notch when the arterial valve closes, the QRS corresponds with the arterial waveform. - if narrow = may not have enough output or may need to zero out system Arterial Line Nursing Monitoring - Correct Answers must perform Allen Test prior to insertion Watch For: - infection - bleeding - airways/lungs (pneumothorax) - Dysrythmias Allen Test - Correct Answers ensures good blood supply through the arteries Raise hand in fist for 30 second. Nurse occludes the ulnar and radial arteries, the lets go of just the ulnar artery. Positive test will show pallor that fades in 7-10 seconds Positive Test = good Negative Test = bad Mean Arterial Pressure (MAP) - Correct Answers correlates to systemic pressure Normal: 70-105 (Diastole X 2) + Systole -------------------------- 3 Greater than 60 = perfuse brain, coronaries, kidneys 70-90 = ideal for cardiac patient Over 65-70 = want to have for critical patients Ventricular Assist Device (VAD) - Correct Answers most common - used to assist the ventricles and decrease the workload of the heart. Heart failure and carcinogenic shock = bridge to transplantation End-stage HF or cardiogenic shock = not improved with inotropic and/or IABP support may be referred for this Monitoring of VAD - Correct Answers observe patient for bleeding, cardiac tamponade, ventricular failure, infection, dysrhythmias, renal failure, hemolysis, and thromboembolism Destination Therapy for VAD - Correct Answers - Right ventricular assist device (RVAD) - Left ventricular assist device (LVAD) - B-ventricular assist device (Bi-VAD) LVAD IS MOST COMMON Extracorporeal Membrane Oxygenation (ECMO) - Correct Answers alternative form of mechanical circulation support therapy for patients with severe acute respiratory distress and/or cardiac failure - deoxygenated blood is diverted from the vascular system via a central vein, and returned to circulation after being oxygenated outside the body - abnormal heart sounds (S4) - N/V - Fever o Initial: increased HR and BP o Later: decreased BP (decreased CO) Right Coronary Artery Occlusion - Correct Answers Right HF: JVD, hypotensions, N/V, bradycardia - due to damage sino-atrial (SA) node Left Main Coronary Artery Occlusion (window maker) - Correct Answers Sudden death, Chronic heart failure, extensive cardiac injury, impairment of heart function, pulmonary congestion, and low cardiac output Complication of Acute Coronary Syndrome - Correct Answers Cardiogenic Shock Cardiogenic Shock - Correct Answers LOW Cardiac output after a Myocardial Infarction - excessive myocardial oxygen demand and inadequate myocardial perfusion worsens myocardial ischemia that leads to death Diagnostic Tests for Acute Coronary Syndrome - Correct Answers o ECG **gold standard for diagnosis of MI** o Coronary angiography - visulization of any obstructions or narrowing of the coronary arteries o Echocardiogram - shows ejection fraction, structural problems, which coronary artery is occluded o TEE - locks at back side of the heart, ensures no clots before cardioversion o Stress test Lab Tests/Results for Acute Coronary Syndrome - Correct Answers o **TROPONIN** - go to lab = most specific to the heart o CK, CK-MB - released when cells are damaged o Ejection fraction - how well is heart pumping o CBC - hemoglobin, hematocrit, white blood cells o Coagulation studies - PT, aPTT, Platelets, ABG Collaborative Care for Acute Coronary Syndrome - Correct Answers Short Term: heparin to prevent clots in coronary arteries Long Term: tPA clot buster to breakup clots Arteries of the Heart - Correct Answers right coronary, left coronary, left anterior descending, circumflex **KNOW WHERE TO LOCATE ON TEST** Acute Coronary Syndrome Medications - Correct Answers Antiplatelets Anticoagulants Narcotics Beta Blockers Nitrates Thrombolytics Antiplatelets - Correct Answers prevents platelets from forming new clots or increasing size of current clots - asprin - clopidogrel (Plavix) - eptifibatide (Integrillin) Anticoagulants - Correct Answers prevent blood clot formation - heparin - enoxaparin (Lovenox) Narcotic - Correct Answers relieves chest pain - morphine sulfate - hydromophone (Dilaudid) Beta Blockers - Correct Answers decrease myocardial workload thus myocardial oxygen demand, limiting extension of injury - metoprolol (Lopressor) - atenolol (Tenormin) - carvedilol - labetalol Thrombolytics - Correct Answers revascularization of the heart muscle by dissolving clots in arteries MONA - Correct Answers Morphine Oxygen Nitroglycerin Aspirin 1. oxygen 2. nitroglycerin 3. aspirin 4. morphine Oxygen - Correct Answers provides and improves oxygenation of ischemic myocardial tissue GIVEN 1ST Nitroglycerin - Correct Answers causes VASODILATION and increases blood flow to myocardium GIVEN 2ND Aspirin - Correct Answers prevents the formation of platelet aggregation and arteries to constrict GIVEN 3RD Morphine - Correct Answers vasodilates and decreases workload of the heart by decreasing preload and afterload GIVEN LAST Cardiogenic Shock Surgical Management - Correct Answers Percutaneous Coronary Intervention (PCI) = revascularization Intra-aortic Balloon Pump (IABP) = increases oxygen supply and decreases demand Ventricular Assist Devices (VAD) = bridge to transplantation ECMO Total Artificial Heart = end-stage heart failure; can't have natural heart transplant Heart Transplants Cardiogenic Shock Nursing Managment - Correct Answers - Deliver oxygen (non-rebreather face mask) - Insert arterial line - Insert PA catheter - Assess vital signs and symptoms Meds: - Give inotrops STAT (dobutamine and epinephrine) - Vasopressors - Nitroglycerins - Diuretics - Morphine Low BP - Correct Answers give dopamine - hypotensive needs IMMEDIATE blood pressure support pulmonary embolism (PE) - Correct Answers obstruction of one of more of the branches of the pulmonary artery. Caused by thrombus or piece of tumor, amniotic fluid, air, or fat Pulmonary Embolism (PE) symptoms - Correct Answers - *sudden onset of dyspnea, SOB* - *accessory muscles being used* - *tachypnea* - pleuritic chest pain - tachycardia - cough - hemoptysis - unilateral low extremity edema, due to DVT Pulmonary Embolism (PE) Treatment - Correct Answers - Oxygen - Pain meds - Fluids and CV meds to correct pressure - Anticoagulants o Heparin - prevent clots from growing and help keep new clots from forming o Warfarin - slow acting o Duration of treatment depends on patient Thrombolytic agent - Streptokinase, urokinase, alteplase, reteplase - Dissolve blood clots (clot-busters) - Excessive risk of bleeding Acute Respiratory Failure (ARF) - Correct Answers one or both gas echange functions of the lungs are compromised; resulting in hypoxemia and/or hypercapnia Hypoxemic Respiratory Failure - Correct Answers gas exchange and oxygenation do NOT occur CAUSED: - V/Q mismatch - A shunt - Impaired diffusion Hypercapnic Respiratory Failure - Correct Answers reduced ability of the lungs and respiratory apparatus to adequatly expand - suboptimal amount of air moved by the lungs - elimination of CO2 is inadequate ARF Causes - Correct Answers - trauma - anaphylaxis - pneumonia - COPD - burns **ALOT OF THINGS** Acute Respiratory Distress Syndrome (ARDS) - Correct Answers Stiff, non compliant lung. Alveoli are NOT flexible with inhalation and exhalation (do not extend properly) - alveoli filled with fluid - dyspnea - hyoxemia with decreased lung compliance - pulmonary infiltrates - PaO2/FiO2 < 200 - pulmonary wedge pressure <18 - bilateral infiltrates on chest radiograph ARDS Treatment - Correct Answers 1. nasal cannula (5-6 litters) 2. high flow nasal cannula (10 litters) 3. breathing mask 4. CPAP 5. BIPAP **have to have a respiratory drive or go to ventilator** ARF Nursing Interventions - Correct Answers - albuterol - ventilator support - prone positioning (helps hypoxia = back can expand more if laying on stomach) Interventions to prevent ventilator associated pneumonia - Correct Answers - Oral care and suctioning EVERY 4 hours - Brush teeth ever 12 hours - Conventional ETT should be replaced with subglottic secretion drainage - Turn patient EVERY 2 hours - Feedings and Fluids (tube feeding) *TURN,WATER,FEED* - decrease respiratory rate to perserve CO2 Nursing Care during Ventilation - Correct Answers - keep head of bed at 30 degrees - use sedation and paralysis - infection control - PUD prophylaxis - VTE prophylaxis - Maintain skin integrity - Comfort - Nutrtion - Communicate needs (psychosocial) - Weaning Trial (30-120 minutes; use CPAP) Extubation - Correct Answers removal of a previously inserted tube - suction - hyperoxygenate - have patient take deep breaths while deflating the cuff and removing the tube - encourage coughing and deep breathing - apply oxygen Closed Suction - Correct Answers inline suction - closed and sterile - through the ventilator tubing = until patient coughs or you meet resistance then suction on the way out *when you suction the ventilator CANT give full settings* - hypoxia may occur - hyperoxygenate before suctioning - suction BELOW the bulb - dysrhythmias related to hypoxia (PVC) Chest Tube Nursing Management - Correct Answers - monitor I and O carefully - monitor the airway - bleeding - infection * DONT: clamp tube or elevate chest tube box above the chest * Chest Tube Removal - Correct Answers use sterile vaseline gauze have biohazard bag nearby have oxygen ready Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care based on a ventilator bundle? Select all that apply. a. Ensuring a sedation vacation each day b. Conducting a readiness to wean assessment c. Elevating the head of the bed d. Administering a prescribed peptic ulcer prophylactic regimen e. Avoiding the use of compression stockings during immobility - Correct Answers a. Ensuring a sedation vacation each day b. Conducting a readiness to wean assessment c. Elevating the head of the bed d. Administering a prescribed peptic ulcer prophylactic regimen Which clinical manifestation indicates to the nurse that a patient is experiencing intermediate respiratory failure? a. Lethargy b. Tachycardia c. Dyspnea d. Restlessness - Correct Answers a. Lethargy The nurse is caring for a patient on the following ventilator settings: FIO2 70%, TV 550, RR 16, PEEP 15. Upon assessment, the nurse recognizes absent breath sounds on the right side. What is the nurse most concerned about? A. Pneumonia B. Tension pneumothorax C. Need for emergency tracheostomy D. Need for higher FIO2 through ventilator settings - Correct Answers B. Tension pneumothorax Which patient statement indicates to the nurse a need for additional teaching regarding the prevention of pulmonary embolism (PE)? a. "I will decrease my intake of saturated fats." b. "I will continue to try to quit smoking by using a nicotine gum." c. "I won't need any blood work since I am being discharged with warfarin." d. "I joined a gym so that I can take an aerobic exercise class." - Correct Answers c. "I won't need any blood work since I am being discharged with warfarin." A Registered Nurse is caring for a patient with an endotracheal tube on a mechanical ventilator. What task can the RN delegate to the LPN A. Suction endotracheal tube for stable patients B. Reposition and secure endotracheal tube C. Administer sedatives, analgesics and paralytic medications as needed D. Monitor ventilator settings and alarms - Correct Answers A. Suction endotracheal tube for stable patients The nurse provides care to a patient admitted for a traumatic brain injury. The patient's arterial blood gas (ABG) analysis indicates respiratory acidosis. Which action by the nurse is best when providing care to this patient? a. Assessing respiratory rate and depth closely b. Administering sodium bicarbonate, per prescription c. Monitoring peripheral vascular status d. Reassuring the patient to decrease anxiety - Correct Answers a. Assessing respiratory rate and depth closely The nurse assists the health-care provider with a patient intubation. Which is the priority action by the nurse? A. Ensure suction is available, if needed. B. Place the intubation tray at the bedside for the procedure. C. Explain each step of the procedure to the patient and family. D. Administer manual breaths to the patient using a resuscitation bag and mask. - Correct Answers D. Administer manual breaths to the patient using a resuscitation bag and mask The nurse suctions a patient's tracheostomy tube. During the procedure, the patient's heart rate drops to the low 50s and oxygen saturation falls to 85%. Which is the priority action by the nurse?