week 2 -- PE, chest trauma, valve diseases, & aneurysms

Question 1

common cause of a PE

Answer 1

DVT

Question 2

ABG’s with a PE tell you

Answer 2

intubate or escalate O2

Question 3

D-dimer

Answer 3

tells you how much fibrins were relaeased to take apart a clot

**higher # = more likely of a clot

**expected rage is less than 0.4 mcg/mL

Question 4

if a patient w allergy to iodine/shellfish cannot do angiography to diagnose PE then they will do a

Answer 4

ventilation perfusion scan—– shows circulation of air and blood in the lungs

Question 5

gold standard to diagnose PE

Answer 5

pulmonary angiography — allergy to shellfish & iodine

Question 6

6 ways to diagnose a PE

Answer 6

1. pulmonary angiography (gold standard)
2. ABG
3. Ventilation perfusion
4. Ct Scan
5. chest x-ray
6. d- dimer

Question 7

interventions for PE

Answer 7

1. initiate o2 & high - fowlers (90 degrees)
2. iv access
3. vitals

Question 8

INR range

Answer 8

describes blood clotting

0.8 to 1.1

Question 9

goal of INR when on warfarin

Answer 9

2 to 3

Question 10

normal pT time

Answer 10

11 to 12.5 seconds

Question 11

normal ApTT time

Answer 11

30 to 40 seconds but 1.5 to 2.5x more w heparin

Question 12

low molecular weight heparin

Answer 12

enoxaparin

Question 13

anticoagulants are contraindicated in

Answer 13

peptic ulcer disease
uncontrolled HTN
stroke
trauma

Question 14

thrombolytic agents are used for

Answer 14

bigger clots

ALTEPLASE
reteplase
tenecteplase

• -eplase

Question 15

therapeutic procedures for a PE

Answer 15

embolectomy
vena cava filter

Question 16

normal PaO2

Answer 16

80 to 100 mmhg

Question 17

vitamin K foods on wafarin

Answer 17

do not increase or decrease

Question 18

teaching to prevent DVT/PE

Answer 18

walk 5 min every hour
compression stockings
dorsi-plantar flexion

Question 19

s/s of decreased cardiac output

Answer 19

hypotension
tachycardia
JVD
cyanosis
syncope

Question 20

antidote for heparin

Answer 20

protamine sulphate

Question 21

antidote for warfarin

Answer 21

vitamin K

Question 22

a nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? sap

1. bradypnea
2. pleural friction rub
3. hypertension
4. petechiae
5. tachycardia

Answer 22

2. pleural friction rub
3. petechiae
4. tachycardia

** tachypnea
**hypotension

Question 23

client has acute dyspnea & diaphoresis. client states “I am anxious & unable to get enough air”. vitals are HR 117/min, RR 38bpm , temp 101.2, and bp of 100/54. what is the nurses priority?

1. notify the provider
2. administer heparin via IV infusion
3. administer oxygen therapy
4. obtain a CT scan

Answer 23

3. administer oxygen therapy

**ABC’s

Question 24

BUN range

Answer 24

7 to 20

Question 25

creatinine range

Answer 25

0.7 to 1.3

Question 26

INR range when on warfarin

Answer 26

2 to 3

Question 27

aPTT goal with heparin therapy

Answer 27

40 to 60 sec

Question 28

PaO2 range

Answer 28

80 to 100 mmhg

Question 29

flail chest is stabilized by

Answer 29

positive pressure ventilation

Question 30

tension pneumothorax occurs when

Answer 30

air enters on INSPIRATION and cannot exit on expiration

Question 31

lung sounds w a pneumothorax

Answer 31

hyper-reasonance

Question 32

lungs sounds w a hemothorax

Answer 32

dull percussion

Question 33

key sign of a flail chest

Answer 33

paradoxical chest movement

Question 34

patient considerations for a thoracentesis

Answer 34

- sit on edge of bed leaned over side table - no coughing, moving, or deep breathing - will feel pressure but no pain

Question 35

a nurse is assisting a provider to care for a client who has developed a spontaneous pneumothorax. which of the following actions should the nurse perform first? 1. assess the client's pain 2. prepare a large bore IV needle for decompression 3. administer lorazepam 4. prepare for chest tube insertion

Answer 35

2. prepare a large bore IV needle for decompression

Question 36

nursing considerations for an angiography

Answer 36

**LYING FLAT NPO for 8 hrs *renal function *iodine/shellfish allergy *withhold metformin for 48hrs before & after post op - pressure on site & lay flat

Question 37

considerations for transesophageal echo

Answer 37

HOB @ 45 degrees NPO 6hrs prior IV access Post op = GAG reflex

Question 38

client education for angiography

Answer 38

report: chest pain, SOB, &changes of colors in extremities leave dressing in place for 24 hrs avoid heavy weight & bending at waist withhold metformin 48 hrs before & after

Question 39

cardiac tamponade nursing interventions

Answer 39

1. notify provider 2. admin IV fluid (combats hypotension) 3. obtain CXR / echo 4. prepare for a pericardiocentesis

Question 40

structures on the left side of the heart

Answer 40

left atrium mitral valve left ventricle aorta

Question 41

structures on the right side of the heart

Answer 41

tricuspid valve right atrium right ventricle pulmonic arteries

Question 42

foods high in potassium and can be given w/

Answer 42

* thiazide & loop diuretics to prevent hypokalemia spinach bananas potateos nuts dried & citrus fruit

Question 43

considerations when taking digoxin

Answer 43

apical pulse greater than 60/min same time every day separate 2 hrs from antacids

Question 44

digoxin toxicity manifestations

Answer 44

visual changes (green halos) confusion muscle weakness fatigue loss of appetite

Question 45

mechanical valves require

Answer 45

life long anti-coagulant therapy *prothrombin checked on a regular basis *kids

Question 46

tissue valves require

Answer 46

replacement every 7 to 10 years older ppl

Question 47

a nurse educator is reviewing expected findings who has right-sided valvular heart disease with a group of nurses. which of the following findings should the nurse include in the discussion? sap 1. dyspnea 2. client report of fatigue 3. bradycardia 4. pleural friction rub 5. peripheral edema

Answer 47

1. dyspnea 2. client report of fatigue 5. peripheral edema

Question 48

expected outcome of a percutaneous balloon valvuloplasty. nurse response

Answer 48

this will assist with the ability to perform activities of daily living

Question 49

a nurse is reviewing the health record of a client who is being evaluated for possible valvular disease. The nurse should recognize which of the following data as risk factors for this condition? 1. surgical repair of an atrial septal defect at age 2 2. hypertension for 5 years 3. weight gain of 10 pounds in the last year 4. diastolic murmur present

Answer 49

1. surgical repair of an atrial septal defect at age 2 2. hypertension for 5 years 4. diastolic murmur present

Question 50

a nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. which of the following findings should the nurse expect? 1. s4 heart sounds 2. petechiae 3. neck vein distention 4. splenomegaly

Answer 50

3. neck vein distention *s3 heart sounds *hepatomegaly

Question 51

risk factors for valvular heart disease

Answer 51

HYPERTENSION RHEUMATIC FEVER marfan syndrome ineffective endocarditis

Question 52

s/s of MITRAL stenosis

Answer 52

**apical DIASTOLIC murmur JVD hepatomegaly dry cough pitting edema afib dyspnea / orthopnea

Question 53

s/s of mitral insufficiency

Answer 53

**SYSTOLIC murmur @ apex atypical chest pain diminished lung sounds hepatomegaly JVD dyspnea / orthopnea

Question 54

s/s of aortic stenosis

Answer 54

SYSTOLIC MURMUR (A.S.S.) NARROWED pulse pressure syncope angina dyspnea / orthopnea

Question 55

s/s of aortic insufficiency

Answer 55

DIASTOLIC murmur WIDE pulse pressure bounding pulse NOCTURNAL angina w diaphoresis tachycardia palpitations

Question 56

aneurysm & types

Answer 56

widening or ballooning of a blood vessel *asymptomatic 1. saccular = one side 2. fusiform = both sides -- complete circumference

Question 57

risk factors for aneurysms

Answer 57

atherosclerosis HTN syphillis hyperlipidemia males trauma tobacco

Question 58

s/s of aortic abdominal aneurysm

Answer 58

pulsating abdominal mass bruit over area low back pain constant gnawing feeling in the abdomen

Question 59

s/s of thoracic aortic aneurysm

Answer 59

SEVERE BACK PAIN COUGH sob difficulty swallowing decreased renal function

Question 60

s/s of aortic disection

Answer 60

assoc. w marfan syndrome tearing, ripping, stabbing hypovolemic shock

Question 61

priority intervention for aneurysms

Answer 61

to reduce systolic between 100 and 120 long term to maintain systolic between 130 to 140

Question 62

nursing interventions for caring for aneurysms

Answer 62

hob below 45 degrees warm environment cough q 2 hrs w splint

Question 63

Beck's Triad

Answer 63

1. hypotension 2. JVD 3. diminshed heart sounds