NUR2571 Professional Nursing II PN 2 Exam 2 Study Guide ., Exams of Nursing

Download NUR2571 Professional Nursing II PN 2 Exam 2 Study Guide . and more Exams Nursing in PDF only on Docsity! 1 -Assess heart rate (HR) and blood pressure (BP) before administration because beta blockers cause a decrease in HR and cardiac output and suppress renin activity. • Do not administer if HR is <50-60 beats/min. • Hold for systolic <90-100 mm HG and contact the health care provider. • Monitor for orthostatic hypotension because this is a common adverse effect that can contribute to falls and confusion, especially in older adults. - Use with caution in patients with diabetes because glucose production may be affected. - Teach the patient that these agents can cause fatigue, depression, and sexual dysfunction. These adverse effects should be reported to the primary health care provider. 2. Complications of atrial fibrillation -Atrial fibrillation occurs commonly in clients with cardiac disease and is a common reoccurrence after coronary artery bypass graft surgery. -Clients are at risk for embolitic stroke. Evidence of embolitic events includes changes I mentation, speech, sensory function, and motor function. -Clients with A-fib often have a rapid ventricular response as a result. - Clients with a-fib are at risk for decreased cardiac output and fatigue when completing activities of daily living. -Nursing Intervention: schedule periods of rest and exercise during the day. -for patients with acute a-fib who have a cardioversion, the nurse should turn off any oxygen therapy to prevent fire. 3. Complications from wide QRS and bradycardia combined, what does it mean? -An HR of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, syncope and seizure activity. 4. What does pacer spikes without QRS complex imply and what complication can it cause? -Pacer spike without QRS complex imply “LOSS OF CAPTURE”. If there is no capture then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. 5. Precautions taken when the nurse uses a defibrillator 1 NUR2571: Professional Nursing II / PN 2 Exam 2 Study Guide 1. Effects of beta-blockers on heart and heart rate -Beta Blocker will decrease Heart Rate and Blood pressure. 2 2 -PRIORITY: Ensure that everyone is clear of contact with the client and the bed** -Epinephrine should be administered AFTER defibrillation 6. Know what V-Tach looks like on monitor and the treatment -You MUST shock someone with ventricular tachycardia via defibrillator AND INITIATE CARDIO-PULMONARY RESUSCITATION (CPR)!!!! 7. Know what bradycardia looks like on monitor and the treatment 8. Know Signs and symptoms of left sided heart failure and right sided heart failure LEFT SIDED HEART FAILURE -Cause for left sided heart failure include mitral and aortic valve disease, coronary artery disease and hypertension. -Orthopnea, coughing, and difficulty breathing could all be results of left sided heart failure, as well as dyspnea on exertion!! -Client may report weakness and fatigue while performing activities of daily living as well as difficulty breathing and catching their breath. EX. walking up the stairs. - The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. RIGHT SIDED HEART FAILURE 5 4 -Nursing Intervention: Nurse should position a client who is experiencing substernal pericardial pain that radiates to the left side of the neck, in a comfortable position which is usually upright leaning forward. (Pain is decreased by gravity to take pressure off the heart muscle.) -Pain from acute pericarditis may worsen when the client lay supine. 14. Know interventions and purpose of cyclosporine -These agents cause immune suppression leaving the client vulnerable to infection. -Client should be taught to avoid large crowds and people who are sick. 15. Complications, including possible cardiac dysrhythmias for mitral valve regurgitation -Atrial Fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. 16. Know normal values for HDL, LDL, Triglycerides, and cholesterol levels -HDL: more than 40mg/dL -LDL: Less than 100mg/dL -Triglycerides: less than 150mg/dL – Triglycerides in men should be below 160mg/dL -Total Cholesterol levels: less than 200mg/dL -Lipid panels are often used to screen for cardiovascular risk* 17. Know possible interactions with OTC medications like herbs, for Coumadin -Many drugs interfere with Coumadin (Warfarin). -ST. Johns wort is one of them. 18. What is the purpose of a transluminal coronary angioplasty? - For peripheral arterial disease. 19. Complications of post-op femoral-popliteal bypass -Once perfusion has been restored or improved to the extremity, clients often feel throbbing pain due to the increased blood flow. -Nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature to differentiate this pain from ischemia. -Dressing changes should be done using the sterile technique along with proper hand hygiene to prevent infection. 20. Nursing assessment and interventions for DVT -Moist packs will help the pain of a DVT (UAP can provide). -Ambulation is not a comfort measure. -Massaging the leg is contraindicated to prevent complications such as pulmonary embolism. -Monitor for Pulmonary Embolism (Oxygen saturation), S/S shortness of breath, chest pain, confusion in older adults -Have patient wear compression stockings for extended periods (ensure proper sizing of compression socks, must fit correctly to work) 6 -Anticoagulant medications 7 -Best Rest -Elevation of the extremities. -Perform range of motion exercises of the legs at least hourly. 21. Goals of Healthy People 2020 related to cardiovascular disease and stroke - An important goal of the HP2020 is to increase the proportion of adults who have had their blood pressure measure within the preceeding 2 years and can state whether their blood pressure was normal or high. Participating in a blood pressure screening in a public setting will best meet this goal. 22. Know side effects and purpose of ace-inhibitors -Administration of the first dose of ACE-inhibitors is often associated with hypotension, usually termed “first dose effect”. -Nursing Interventions: nurse should instruct the client to seek assistance when rising from bed to prevent injury. -Nurse should monitor for signs of hyperkalemia especially if the client has renal insufficiency secondary to hear failure. -ACE inhibiters such as enalapril inhibit the excretion of potassium. Hyperkalemia is a life-threatening side effect and clients should be taught to limit potassium intake. (SALT SUBSTITUES ARE COMPOSED OF POSTASSIUM CHLORIDE) - New onset of cough -Nursing Intervention: Assess the client lung sounds and oxygenation FIRST before assuming side effect of medication. **Always assess respiratory first! 23. Know what PAD is and what it looks like, as well as the treatment and interventions -PAD is peripheral Arterial Disease and it occurs in disorders that altar the natural flow of blood through the peripheral arteries and veins, causing decreased tissue perfusion, especially to the lower extremities. -Most patients with PAD are not diagnosed until they develop leg pain. -Skin will be cool, pale and moist in extremities because of decreased perfusion. -As PAD progresses, it takes less oxygen demand to cause pain. -Patients will experience leg pain known as intermittent claudification, causing them to be able to walk only certain distance before a cramping, burning muscle discomfort or pain forces them to stop. (Needing to cut down on activity to be pain free indicates that the disease is worsening.) -Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result*** 5 10 -Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. - *Client at risk for PE- ASSESS RESPIRATORY FIRST! 30. Know interventions and treatment of neutropenia (Low white blood cell count) -Clients with neutropenia often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. -Nurse should always assess these clients for infection FIRST! -Priority intervention is protecting patient from infection in the healthcare setting. -Teaching the patient and family how to reduce infection risk in the home -Place the patient in a private room -Monitor vitals every 4 hours including temp. -Monitor WBC daily. -Restrict fresh flowers and potted plants. 31. Know post-op interventions for a bone marrow transplant - Providing hope is an essential nursing function during the recovery period after a bone marrow transplant which can take up to 3 weeks. -Post intervention: Put the patient on bleeding precautions due to impaired clotting. -Assess patient at least every 4 hours for oozing, bleeding, petechiae and purpura (blood spots or skin hemorrhaging, looks like purple dots) -Inspect stool, urine and vomit for blood -Measure blood loss -Increased abdominal girth can indicate abdominal hemorrhage 32. Know what graft-versus-host disease is -Autoimmune type process in which donor cells recognize the client’s cells as foreign and begin attacking them. -The donor cells are attacking the clients cells 33. Know normal value for platelet count, and complications when it is low -Normal platelet count is 150,000-450,000* -Patient is at risk for bleeding injury -Place patient on safety precautions if platelet count is below normal value 34. Know complications of medication called droxia, used in sickle cell patients -Clients with SCD often have elevated WBC, extreme elevation could indicate leukemia, a complication of taking hyrozyurea. -Nurse should immediately report an elevated WBC** 35. Complications of leukemia -Clients at risk for infection. -In leukemia, the WBCs do not provide protection to the client against infection. 8 11 -Fatigue is a common problem for clients with leukemia. 12 9 -Client performing their own ADLs using rest periods demonstrates an understanding of client managing the symptoms -Client may hemorrhage in the GI tract and should be assessed as a PRIORITY! (blood in stool) 36. Complications of B12 anemia -Client has glossitis, and this is a characteristic of B12 anemia!!!! -If the anemia is pernicious anemia, it is treated with cobalamin. *NEED ORDER AND CONSENT FOR BLOOD TRANFUSIONS!!