ATI: Chapter 24 - TB Flashcards
(104 cards)
1
Q
A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a ______ in the pulmonary vasculature.
A
blockage
2
Q
____ originating from venous thromboembolism, also known as deep vein thrombosis (DVT), are the most common cause.
A
Emboli
3
Q
Tumors, bone marrow, amniotic fluid, air and ______ also can become emboli.
A
foreign matter
4
Q
Increased ______ to pulmonary tissue and impaired blood flow can result from a large embolus. A PE is a medical emergency.
A
hypoxia
5
Q
Prevention, rapid recognition, and treatment of a PE are essential for a _______ outcome.
A
positive
6
Q
Promote smoking _____.
A
cessation
7
Q
Encourage maintenance of appropriate _______ for height and body frame.
A
weight
8
Q
Encourage a healthy diet and ______.
A
physical activity
9
Q
Prevent DVT by encouraging clients to do leg exercises, wear compression stockings, and avoid ______ for long periods of time.
A
sitting
10
Q
A risk factor for a pulmonary embolism includes long-term _______.
A
immobility
11
Q
A risk factor for a pulmonary embolism includes the use of _______ and estrogen therapy.
A
oral contraceptives
12
Q
A risk factor for a pulmonary embolism includes women who are _____.
A
pregnant
13
Q
A risk factor for a pulmonary embolism includes people who use ______.
A
tobacco
14
Q
A risk factor for a pulmonary embolism includes hyper_________.
A
coagulability (elevated platelet count)
15
Q
A risk factor for a pulmonary embolism includes _______, especially orthopedic of the lower extremities or pelvis.
A
surgery
16
Q
A risk factor for a pulmonary embolism includes _______ catheters.
A
central venous
17
Q
A risk factor for a pulmonary embolism includes heart failure or chronic ________.
A
atrial fib
18
Q
A risk factor for a pulmonary embolism includes__________ anemia (sickle cell)
A
autoimmune hemolytic
19
Q
A risk factor for a pulmonary embolism includes ______ fractures.
A
long bone
20
Q
A risk factor for a pulmonary embolism includes trauma, ________, and advanced age.
A
cancer
21
Q
Older adult clients have _______ pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli. Older adult clients can decompensate more quickly.
A
decreased
22
Q
Certain pathological conditions and procedures that predispose clients to ______ formation (peripheral vascular disease, hypertension, hip and knee arthroplasty) are more prevalent in older adults.
A
DVT
23
Q
Many older adult clients experience decreased physical activity levels, thus predisposing them to DVT formation and _______.
A
pulmonary emboli
24
Q
Expected findings of a PE include: (7)
A
anxiety feelings of impending doom pressure in chest pain upon inspiration and chest wall tenderness dyspnea and air hunger cough hemoptysis
25
Physical findings of a PE include:
```
pleurisy
pleural friction rub
tachycardia
hypotension
tachypnea
adventitous breath sounds (crackles and cough
heart murmur in S3 and S4
Diaphoresis
low grade fever
decreased oxygen saturation levels (expected reference range is 95% to 100%), low SaO2, cyanosis
Petechiae (red dots under the skin) over chest and axillae
Pleural effsion (fluid in the lungs)
Distended neck veins
Syncope
Cyanosis
```
26
_______ analysis is used to monitor hemoglobin and hematocrit.
CBC
27
As hypoxemia progresses, _______ occurs.
respiratory acidosis
28
Further progression leads to _______ due to buildup of lactic acid from tissue hypoxia.
metabolic acidosis
29
PaCO2 levels are _____ due to initial hyperventilation (respiratory alkalosis).
low
30
D dimer is _____ above expected reference range in response to clot formation and release of fibrin degradation products (expected reference range is 0.42 to 2.33 mcg/mL)
elevated
31
PE diagnostic procedures
Chest x ray and CT scan
Ventilation-perfusion scan
Pulmonary angiography
32
PE Lab Tests
ABG analysis
CBC analysis
D-dimer
33
_______ and ________ provide initial identification of a PE. A computed tomography (CT) scan is most commonly used. A chest x-ray can show a large PE.
chest x ray and CT scan
34
________ scan images show circulation of air and blood in the lungs and can detect a PE.
Ventilation-perfusion (V/Q)
35
_______ is the gold standard and most thorough test to detect a PE, but it is invasive and costly. A catheter is inserted into the ______ to visually see a PE>
vena cava
36
Pulmonary angiography is a ______ risk procedure than a V/Q scan.
higher
37
Verify that informed consent must be obtain for a ______.
pulmonary angiography
38
Monitor status (vital signs, SaO2, anxiety, bleeding with angiography) during and after the _______.
pulmonary angiography
39
Administer oxygen therapy to relieve hypoxemia and dyspnea. Position the client to maximize ______ (high-fowlers = 90 degrees)
ventilation
40
Initiate and maintain _____ access for patients with a PE.
IV
41
Administer medications as _____.
prescribed
42
Assess respiratory status at least every ______ with a PE.
30 minutes
43
When assessing respiratory status ausculate lung sounds, measure ______ and ______, and ease of respiration. Inspect skin color and capillary refill. Examine for position of the _____.
rate and rhythm
trachea
44
Assess the ______ status with a pulmonary embolism. Compare bp in both arms. Palpate pulse _______. Check for dysrhythmias on cardiac monitor. Examine the neck for distended neck veins. Inspect the thorax for _______.
cardiac
quality
petechiae
45
Provide emotional support and comfort to control client _______ for patients with a PE.
anxiety
46
Monitor changes in level of consciousness and _______ of patients with a PE.
mental status
47
Anticoagulants (4)
heparin
enoxaparin
warfarin
fondaparinux
48
Anticoagulants are used to prevent _____ from getting larger or additional clots from forming.
clots
49
Assess for contraindications to ________ (active bleeding, peptic ulcer disease, history of stroke, recent trauma)
anticoagulants
50
Monitor bleeding time: _______ = (PT)
Prothrombin time
51
Monitor bleeding time: international normalized ratio (INR) for ______.
warfarin
52
Monitor bleeding time: parital thromboplastin time (aPPT) = _______ and CBC
heparin
53
Monitor for side effects of anticoagulants such as thrombocytopenia, anemia, or _______.
hemorrhage
54
Rivaroxaban binds directly with the active center of factor Xa, which inhibits the production of _______.
thrombin
55
Assess for bleeding from _____. (Clients have experienced epidural hematomas, as well as intracranial, retinal, adrenal, and GI bleeds)
any site
56
Risk for spinal or ______ hematoma with direct factor Xa inhibitor. Should discontinue medication for 18 hours prior to removing an epidural catheter, and wait another ____ hours to restart.
epidural
| 6
57
Thrombolytic therapy (3)
Alteplase
Reteplase
Tenecteplase
58
_______ therapy is used to dissolve blood clots and restore pulmonary blood flow.
thrombolytic
59
Thrombolytic and ______ have similar side effects and contraindications.
anticoagulants
60
Side effects of thrombolytic agents include ______, anemia, or hemorrhage.
thrombocytopenia
61
Assess patients taking thrombolytic agents for contraindications such as bleeding disorders, uncontrolled hypertension, active bleeding, ________, history of stroke, recent trauma or surgery, pregnancy.
peptic ulcer disease
62
Monitor BP, heart rate, _________, and oxygen saturation per facility protocol before, during, and after administration of thrombolytic therapy.
respirations
63
Cardiology and ______ services should be consulted to manage a PE and treatment.
pulmonary
64
Respiratory services should be consulted for oxygen therapy, breathing treatments, and ______.
ABGs
65
_________ should be consulted for diagnostic studies to determine PE.
Radiology
66
Surgical removal of embolus is called a _____.
embolectomy
67
Prepare the client for the embolectomy by making sure there is informed consent and is on _______ status.
NPO
68
Monitor embolectomy patients monitor postoperatively (vital signs, _____, incision drainage, pain management)
SaO2
69
If the PE client is homebound, set up home care services to perform ____ blood draws.
weekly
70
Set up referral services for PE patients to supply portable oxygen for client who have _________.
sever dyspnea
71
Provide education about treatment and prevention of a PE. Promote ______ cessation if the client smokes. Encourage the client to avoid long periods of ________.
smoking
| immobility
72
Provide education about treatment and prevention of a PE. Encourage ______ such as walking. Encourage the client to wear compression stockings to promote circulation. Encourage the client to avoid _____ the legs.
physical activity
| crossing
73
Advise the client to monitor intake of food high in ________ (green, leafy vegetables) if taking warfarin. _____ can reduce the anticoagulant effects of warfarin.
Vitamin K
| Vitamin K
74
Advise the client to adhere to a schedule for monitoring PT and ______, follow instructions regarding medication dosage adjustments (for clients on warfarin), and adhere to weekly blood draws.
INR
75
Remind the client of the increased risk for ______ and bleeding.
bruising
76
Instruct the client to avoid taking _______ products unless specificed by the provider.
aspirin
77
Encourage the client to check his _____ and skin daily for bleeding and bruising.
mouth
78
Encourage the client to use electric shavers and _______.
soft bristled toothbrushes
79
Instruct the client to avoid blowing his nose hard, and to gently apply pressure if _______ occurs.
nose bleeds
80
Encourage clients who travel about measure to prevent PE. Instruct the client to arise from a sitting position for 5 min out of every _____.
hour
81
Encourage clients who travel about measure to prevent PE. Advise the client to wear ______.
support stockings
82
Encourage clients who travel about measure to prevent PE. Inform the client to remain hydrated by drinking ______.
plenty of water
83
Encourage clients who travel about measure to prevent PE. Instruct the client to perform active ROM exercises when ____.
sitting
84
A complication of a PE is decreased ________ due to decreased blood volume.
cardiac output
85
Pts with a PE and decreased CO monitor for ______, tachycardia, cyanosis, jugular vein distention, and syncope.
hypotension
86
Pts with a PE and decreased CO assess for the presence of ____ or _____.
S3 or S4
87
Pts with a PE and decreased CO initiate and maintain ______.
IV access
88
Pts with a PE and decreased CO monitor _______ (should be more than 30 mL/hr or more)
urinary output
89
Pts with a PE and decreased CO administer ______ (crystalloids) to replace vascular volume.
IV fluids
90
Pts with a PE and decreased CO monitor ______ pressures. IV fluids can contribute to pulmonary hypertension for clients who have right-sided heart failure (cor pulmonale)
pulmonary
91
Pts with a PE and decreased CO administer _______ to increase myocardial contractility.
inotropic agents
92
Pts with a PE and decreased CO _______ can be needed if pulmonary artery pressure is high enough to interfere with cardiac contractility.
vasodilators
93
Pts with a PE can develop _____ as a complication which is a risk for bleeding increased due to anticoagulant therapy.
hemorrhage
94
Pts with a PE and a hemorrhage complication need to be assessed for ____, bleeding, or bruising from injection and surgical sites at least every ______.
oozing
| 2 hours
95
Pts with a PE and a hemorrhage complication need to be monitored for _____ status (BP, HR, and rhythm).
cardiac
96
Pts with a PE and a hemorrhage complication should be given _______ and blood products as required.
IV flids
97
Pts with a PE and a hemorrhage complication should be monitored for _______ and bleeding times.
CBC
98
Pts with a PE and a hemorrhage complication should test _______, urine, and vomit for occult blood.
stools
99
Pts with a PE and a hemorrhage complication should be monitored for _______ (measure abdominal girth and abdominal or flank pain) at least every ______.
internal bleeding
| 8 hours
100
A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism?
A. A client who has a BMI of 30.
B. A female client who is postmenopausal.
C. A client who has a fractured femur.
D. A client who is a marathon runner.
E. A client who has a chronic atrial fibrillation.
A. A client who has a BMI of 30.
C. A client who has a fractured femur.
E. A client who has a chronic atrial fibrillation.
101
```
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4 deg C (101.2 deg F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
```
C. Administer oxygen therapy.
102
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
A. "I am allergic to morphine."
B. "I take antacids several times a day."
C. "I had a blood clot in my leg several years ago."
D. "It hurts to take a deep breath.
B. "I take antacids several times a day."
Rationale: The greatest risk to the client is the possibility of bleeding from a peptic ulcer.
103
```
A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? Select all that apply.
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
```
B. Pleural friction rub
D. Petechiae
E. Tachycardia
104
A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count
A. Hip arthroplasty 2 weeks ago
Rationale: Risk of hemorrhage from the surgical site
