Nursing Care for Patients with Cardiovascular and Respiratory Conditions, Exams of Nursing

Download Nursing Care for Patients with Cardiovascular and Respiratory Conditions and more Exams Nursing in PDF only on Docsity! CCRN CRITICAL CARE REGISTERED NURSE EXAM LATEST 2023/2024 QUESTIONS AND 100% CORRECT ANSWERS TEST BANK The nurse is caring for a patient with acute inferior wall MI, post-coronary artery stent deployment, For optimal care of the patient, the nurse should: - ANSWER>>Continuously monitor the patient in lead II It is best practice to monitor the patient status post PCI with stent, in the lead that was most abnormal during the acute occlusion. The ECG demonstrates ST elevation in leads II, III and aVF. The nurse needs to monitor the patient closely for which of the following? - ANSWER>>Complication likely to occur after an acute inferior wall MI include bradycardia secondary to ischemia to the SA and/or AV node, and papillary muscle rupture or dysfunction due to the anatomical distance between the RCA and the papillary muscle. Which of the following hemodynamic profiles would benefit from the aggressive fluid administration, pressers and antibiotics therapy? a. RAP: 1mm Hg; PAOP: 4 mmHg; SVR: 1800 dynes/sec; CO: 2L/min b. RAP: 5; PAOP: 7; SVR: 400; CO; 8L - ANSWER>>B. the hemodynamic profile of RAP 5, PAOP 7, SVR 400 is typical of septic shock, and choice B would be the best approach. Which of the following is indicative of a mixed acid-base disorder? A. pH 7.18; PaCO2 25; PaO2 64; HCO3 11 B. pH 7.33; PaCO2 29; PaO2 72; HCO3 15 - ANSWER>>The decrease in PaCO2 is evidence of respiratory alkalosis and the decreased HCO3 is evidenced of a metabolic acidosis. The pt with severe sepsis or septic shock may present with this mixed acid-base disorder. The patient with a temporary pacemaker develops pacemaker malfunction. The oriented is instructed to reposition the patient to try and correct the problem. The cardiac monitor most likely demonstrates? - ANSWER>>Failure to capture (pacemaker without a QRS) may be corrected by repositioning the patient to the side. The patient with diastolic heart develops SVT, heart rate 220/min. The most dangerous hemodynamic effect is a decrease in: - ANSWER>>coronary artery perfusion. Diastolic heart failure results in a problem with left ventricular FILLING secondary to ventricular thickening, and contractility and ejection are maintained in diastolic failure. The rapid heart rate will decrease filling time, worsen left ventricular filling and because coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. The patient is receiving heparin infusion for the treatment of pulmonary embolism. There has been a 60% decrease in the platelet count and no clinical change. Which of the following is indicated? - ANSWER>>Discontinue heparin and being argatroban. The patient most likely has HIT. Exposure to heparin needs to discontinued and a direct thrombin inhibitor started for continued anticoagulation. The patient with oat cell carcinoma has the following clinical findings: low urine output, low serum osmolality, hyponatremia, and elevated urine sodium. The nurse anticipates which of the following as part of the treatment plan? - ANSWER>>Phenytoin (Dilantin), 3% saline. The patient has signs of SIADH which results in production of excessive ADH. Dilantin will inhibit ADH secretion and 3% saline will increase serum sodium. Peep therapy and mechanical ventilation are ordered for the patient with acute respiratory failure. Which of the following is a possible complication? - ANSWER>>Barotrauma The addition of positive end-expiratory pressure will increase alveolar recruitment, prevent atelectasis and improve oxygenation. However, the increase in intrathoracic pressure may lead to pneumothorax or subcutaneous emphysema. The postoperative thoracic surgery patient has bubbling in the water seal drainage chamber of the chest tube. Which of the following interventions is indicated? - ANSWER>>avoid high airway pressures Bubbling in the water seal chamber is due to a pleural air leak, and high airway pressure will either prevent resolution of the current air leak or make it worse. Which clinical sign might patients with both systolic and diastolic heart failure have in common? - ANSWER>>Lung crackles Both a problem with systolic (ejection problem) and diastolic (filling problem) will increase left heart pressure and cause cardiogenic pulmonary edema (lung crackles). Which of the following is most likely to result in a low Sv02? A. Hypotermia B. Fever C. Severe sepsis - ANSWER>>Fever Fever increases metabolic rate and consumption, which may lead to a drop in mixed venous oxygen saturation. The nurse needs to assess adequacy of the tubing/catheter system for the arterial line. Which of the following interventions will best assess this? - ANSWER>>Perform a square wave test The patient requires fluid resuscitation and 8 units of PRBC's status post traumatic injury. Which of the following interventions is most appropriate? - ANSWER>>Warm blood products and crystalloids Emergent surgery is essential for survival, and blood pressure control is essential preoperatively. Pain control and transfusion may be indicated, but the remaining therapies are not beneficial. Inferior MI is associated with? - ANSWER>>RCA occlusion AV conduction disturbances: 2nd- degree Type 1, 3rd- degree heart block, Sick sinus syndrome, and sinus bradycardia Development of systolic murmur: mitral valve regurgitation secondary to papillary muscle rupture Also associated with RV infarct and posterior MI Right Ventricular Infarct S&S: What to avoid: - ANSWER>>JVD at 45 degrees High CVP Hypotension Usually clear lungs Bradyarrhythmias Avoid Preload reducers - nitrates, diuretics and caution with beta blockers Anterior MI Reciprocal changes in LAD? May develop? - ANSWER>>reciprocal changes (ST depression) in inferior wall (II, III, aVF) may develop 2nd degree type II or RBBB (the LAD supplies the common bundle of HIS)...ominous sign. Higher mortality than inferior: Heart Failure Complications of PCI: - ANSWER>>Stent thrombosis is most likely to be on the test (most incidents occur acutely within 24hours of stent placement or sub acutely within the first 30 days. Retroperitoneal bleed is most likely to be on test What two drugs do you use for HTN crisis/emergency? - ANSWER>>Nitroprusside and Labetalol Nitro is a preload and afterload reducer. Assess for cyanide toxicity secondary to drug metabolite (Thiocyanate): mental status change (restlessness, lethargy), tachycardia, seizure, a need for increase in dose. Tests to use for PAD? - ANSWER>>Ankle-brachial Index - used to access lower extremity perfusion; normal is greater than 1 Doppler ultrasound testing Arteriography Position for PAD patient? - ANSWER>>Bed in reverse Trendlenburg Do NOT elevate the affected extremity - will decrease perfusion Meds: Thromolytics, Anticoagulants, ASA, Vasodilators Drugs that cause Prolongation of the QT interval ? - ANSWER>>Procainamide, haloperidol, quinidine, amiodarone Electrolyte problems: hypokalemia, hypocalcemia, hypomagnesemia Pacemaker code: - ANSWER>>First initial: Paced 2nd initial: Sensed 3rd: inhibited What is contraindicated with Diastolic heart failure? - ANSWER>>Positive inotropes Dehydration further worsens filling Tachyarrhythmias decrease filling time and worsen symptoms Chest x-ray finding in systolic heart fx? - ANSWER>>may be evidenced by large, dilated heart or by normal heart size on chest film. Causes of Right side heart failure? - ANSWER>>Acute RV infarct Pulmonary Embolism Septal defects Pulmonary stenosis/regurgitation COPD Pulmonary htn Left Ventricular fx Cause of Left sided heart failure? - ANSWER>>CAD, ischemia Myocardial infarction Cardiomyopathy Fluid overload Chronic, uncontrolled htn Aortic stenosis/insufficiency Mitral stenosis/insufficiency Cardiac tamponade IABP: Inflates and deflates when? - ANSWER>>Inflates at the dicrotic notch of the arterial waveform, beginning of diastole Defeats right before systole begins - determined by set trigger for deflation, R wave of ECG or upstroke of the arterial pressure wave Post-Op CABG Assessment for complications of CABG: - ANSWER>>Tamponade Pericarditis Mediastinal tubes remove what? - ANSWER>>serosanguinous fluid from the operative site; whereas pleural chest tubes remove air, blood, or serious fluid from the pleural space. Treatment of Aneurysms: - ANSWER>>Aneurysms less than 5cm in diameter and no symptoms: Monitor regulary - ultrasound or CT scan, treat htn: drug choice is beta blockers, which may slow growth. Thoracic aneurysms causing symptoms or greater than 6cm: Surgical repair Disection: Surgery Aggressive treatment of htn and heart rate control - labetalol drip Neuro Assessment: First sign of a neuro problem? - ANSWER>>LOC - except for an epidural hematoma that may cause pupil changes before an LOC change. GSC Score: - ANSWER>>15 (best) 3 (worst) If the score is 8 or less, outcome is poor Which is worse, obtunded or stuporous? - ANSWER>>Stuporous - pt cannot speak, moan, grimace. Obtunded - can speak, mumble words. Uncle Herniation: - ANSWER>>Lateral shift, NO initial change in LOC Most often caused by epidural hematoma that occurs in temporal area, some strokes Central Herniation: - ANSWER>>Swelling on both sides, downward displacement of hemispheres Slight change in LOC and then coma First both pupils are small (1-3mm) then parasympathetic innervation on both sides is suppressed and both pupils dilate Treatment of Vasospasm? - ANSWER>>Prevent vasospasm by providing CCB - nimodipine (Nimotop) 60mg q 4hrs, for aneurysmal SAH The first sign of an increase in ICP? - ANSWER>>LOC since the "higher" centers of the brain show symptoms first and then progress down toward the brain stem. Hypotension in the presence of Elevated ICP? - ANSWER>>Can be devastating!!! Higher MAP is better than low MAP Brain death is less 30mmHg A patient with a history of a-fib developed arm weakness, blurred vision, and facial droop 5 hours ago. What should the nurse initially anticipate? - ANSWER>>a non-contrast CT scan to determine if it is ischemic or hemorrhagic stroke What signs would indicate that the pt is not tolerating the ventriculostomy? - ANSWER>>Leakage from the ventriculostomy site. Causes of Pancreatitis ? - ANSWER>>*Destruction of gallstones and pancreatic ducts *Alcoholism Trauma What disturbances do you develop during pancreatitis? - ANSWER>>Hypocalcemia and HHNK (hyperglycemia),left sided atelectasis and left sided pleural effusion and bilateral rales. What do people with pancreatitis die from? - ANSWER>>ARDS - it kills type II alveolar cells Why do people with liver dz not clot well? - ANSWER>>they don't have prothrombin and fibrinogen High levels of ammonia leads to what? - ANSWER>>hepatic encephalopathy Why do you not want people with liver dz to develop low potassium levels? - ANSWER>>because of the kidney will hold onto potassium which leads to high ammonia levels. BUN in liver dz? - ANSWER>>breakdown of BUN releases ammonia - so make sure patient is not dehydrated because this will lead to high levels of BUN Do you want people with liver dz to have high levels of protein? Why not? Do you want people with liver dz to have an increase in acid? - ANSWER>>No - it leads to ammonia which will lead to hepatic encephalopathy No! Metabolic acidosis due to low BP Do you give Ringers Lactate to someone with Liver dz? - ANSWER>>No! It cannot convert to bicarb because of the liver dz - it will convert to lactic acid Which medication do you give to someone with liver dz? - ANSWER>>Neomycin - because it does not release ammonia, BUT it leads to Vitamin deficiency How to tell if you have hepatic failure or billiary tract dz? - ANSWER>>Bilirubin and albumin are unconjucated until they go to the liver, where they get conjucated and go to the gallbladder. If someone has indirect or unconjucated bilirubin is it hepatic failure or billiary tract dz? - ANSWER>>Hepatic failure Opposite would be gallbladder problem Ruptured spleen has what signs? - ANSWER>>Kehrs sign - left shoulder pain What does diuretics do to someone with liver dz? - ANSWER>>Lowers their potassium Pre renal failure: - ANSWER>>kidneys are healthy, but blood is not getting down to the kidneys, so no urinary output. TX: FLUIDS or INOTROPIC DRUGS Renal stage of acute renal failure: - ANSWER>>Kidney damage - most common cause is acute tubular necrosis Nephrotoxicity is caused by: - ANSWER>>eating heavy metals/Meds/street drugs/ rhabdomyolysis How to tell Pre renal vs Renal? - ANSWER>>Pre renal - needs fluids and inotropic drugs - check urinary sodium level: 20 or less is pre renal. Check BUN/Creatinine levels: BUN 20:1 or Bun of 60 and creatinine of 3 is pre renal Renal - urinary sodium level: 40 or more is renal stage. BUN/Creatinine levels: BUN 10:1 Bun of 60 and Creatine 6 is Renal Treatment for hyperkalemia ? - ANSWER>>Calcium chloride and insulin and glucose and sodium bicarbonate People with kidney dz always have a low what? - ANSWER>>Calcium or high phosphate levels. This will lead to C&T signs. Low potassium levels S&S? - ANSWER>>U wave and ST depressions Sympathetic Nervous System increases what? - ANSWER>>Heart rate and contractility which maintains B/P Compensatory Phase of Shock: - ANSWER>>B/P maintained Tachycardia Skin pale, cool (except in early sepsis) Progressive Phase of Shock: - ANSWER>>Hypotension Clammy, mottled skin Further change in LOC Refractory Phase of Shock: - ANSWER>>Multisystem organ dysfunction Hypovolemic Shock effects on pulse pressure: - ANSWER>>NARROW pulse pressure Systolic decreases, diastolic maintains or elevates Do you give pressors for Hypovolemic shock? - ANSWER>>No! SVR is already high due to compensatory mechanism SIRS criteria: - ANSWER>>Must have 2 or more of the following: Temp > 38*C or < 36*C Heart rate > 90 Resp > 20 bpm WBC > 12,000 or < 4,000 OR bands > 10% (shift to the left) Sepsis clinical manifestations: - ANSWER>>must include 2 or more of the SIRS criteria plus a documented infection (culture) or suspected infection. Suspected infection is the presence of one or more of the following: *positive culture results from blood, sputum, urine, etc. *receiving antibiotic, anti fungal, or other anti-infective therapy *altered mental status in elderly *possible pneumonia (infiltrate on chest radiograph) Severe Sepsis: - ANSWER>>sepsis PLUS markers of organ dysfunction. Examples of organ dysfunction: Hypotension Acute hypoxemia Lactate greater than 2 Platelets below 100,000 Septic shock: - ANSWER>>septic shock is severe sepsis plus one of the following: *Systemic MAP < 65mmHg despite adequate fluid resuscitation *Maintaining the MAP>65 requires a pressor, e.g., levo, dopamine, epi. S&S of early Septic Shock: S&S of late Septic Shock: - ANSWER>>Tachycardia, bounding pulse B/P normal or low Skin warm, flushed Respirations deep, somewhat fast Fever (temp>38C) Hypotension Tachycardia, pulse weak and thready Skin cool, pale Temp <36C The patient with severe sepsis or septic shock always has positive blood culture T/F? - ANSWER>>True What is the reversal agent for benzodiazepine? - ANSWER>>Flumazenil (Romazicon) Tylenol poisoning: - ANSWER>>N-acetylcysteine (MUCOMYST), dosing effective for 8 hours after ingestion Diuretics can cause both hypokalemia and metabolic alkalosis T/F? - ANSWER>>True How would carbon dioxide levels change with an increase in minute ventilation? - ANSWER>>PaCO2 levels would go down, and end-tidal carbon dioxide would go down. An increase in minute ventilation would increase ventilation, so the PaCO2 and the end-tidal carbon dioxide would go down. Remember that the PetCO2 is usually 1 to 5 mm Hg below the PaCO2. Acute pancreatitis causes elevations in serum amylase, serum lipase, and possibly bilirubin, whereas calcium and albumin are decreased T/F? - ANSWER>>True The primary result of carbon monoxide poisoning is: - ANSWER>>Hypoxia Which of the following sign or symptom is most specific to a small-bowel obstruction? - ANSWER>>Vomiting of fecal matter Remember that time is muscle, so reperfusion is the priority. Also remember an actual problem (decreased contractility) takes priority over a potential problem (dysrhythmias) T/F? - ANSWER>>True patient returns to the critical care unit after insertion of a transvenous pacemaker. There are pacing spikes not followed by a QRS. Which of the following is a method to facilitate capture during pacing? - ANSWER>>Increase milliamperage Consider that failure to capture occurs when the electricity from the pacemaker does not cause depolarization of the ventricle (or atria if an atrial pacemaker). It would be logical to consider using more electricity (i.e., milliamperage). Which of the following statements about colloids is correct? - ANSWER>>They increase intravascular colloidal oncotic pressure. She has had a craniotomy to evacuate the clot, and an intraventricular catheter was placed during surgery. While the nurse is monitoring the patient's intracranial pressure (ICP), the pressure climbs to 40 mm Hg but returns to 15 mm Hg almost immediately. This describes which of the following? - ANSWER>>B wave Normal ICP has a pressure of 5 to 15 mm Hg. An elevation of ICP to 20 to 50 mm Hg occurring every 30 seconds to 2 minutes is a B wave. An elevation of ICP to 50 to 100 mm Hg lasting longer than 2 minutes is an A wave. An elevation of ICP to 20 to 25 mm Hg every 4 to 8 minutes is a C wave. What three things tell you heart catheter has flipped back into right ventricle? - ANSWER>>Three things tell you that the catheter has flipped back into the right ventricle: drop in diastolic pressure, loss of dicrotic notch, and initiation of ventricular ectopy. Which of the following is the preferred lead for ST segment monitoring for a patient with a suspected left anterior descending (LAD) artery occlusion? - ANSWER>>V3 Normal osmolality of body fluids? - ANSWER>>275-295 Normal urine osmolality? - ANSWER>>1.010 - 1.020 What is the biggest danger to hyponatremia? - ANSWER>>Seizure What is the dilute urine range of DI? - ANSWER>>1.001 - 1.005 Treatment of DI? - ANSWER>>Give ADH (Pitressin, DDAVP) Characteristics of DKA? - ANSWER>>Blood sugar: >250 Elevated potassium in the presence of acidosis, although total body potassium is low, it decreases as acidosis is corrected Younger/Type 1 diabetes Insulin production: No Breathing pattern: Kussmaul Tx for DKA: - ANSWER>>Insulin, fluids 0.9 saline, 0.45 saline (if sodium high and B/P normal or high) Decrease blood sugar by 50-100 mg/hr Add dextrose to IV fluids after serum glucose reaches - 250mg Continue insulin infusion until acidosis is resolved Characteristics of HHNK: - ANSWER>>Older Type 2 diabetes Pancreatitis >600 blood sugar Insulin production: Yes Serum K: Often elevated due to insulin deficiency Tx for HHNK: - ANSWER>>Fluids, insulin 0.9 saline Decrease blood sugar by 50-100mg/hr Add dextrose to IV fluids Definitive test for DIC: - ANSWER>>FSP Normal: <10 Fibrinogen is 200-400 Tx for DIC: - ANSWER>>Eliminate the cause Vit K Platelets FFP (Fresh frozen plasma) Cryoprecipitate Heparin (low dose) is controversial so may not see it on test. S&S of HIT: - ANSWER>>Platelets < 150,000 or drop 30% to 50% Early sign - PETECHIAE Clots may lead to PE, MI, stroke, amputation Tx for HIT: - ANSWER>>Stop HEPARIN (fractionated as well as unfractionated) Test for presence of heparin antibodies, ELISA, but do not wait for test results to stop heparin and start treatment Start warfarin Platelets < 10,000, monitor for changes in LOC (intracranial bleed) What is decreased in Cardiogenic shock: - ANSWER>>BP CI/CO SvO2 Everything else is increased: RAP/PAOP/PAP/SVR/PVR What is increased in hypovolemic shock? - ANSWER>>SVR Everything else is decreased What is increased in Septic shock (early)? - ANSWER>>CO/CI/SV/SvO2 What is increased in Septic shock (late)? - ANSWER>>Just SVR and maybe PAOP What is decreased in pulmonary edema? - ANSWER>>CO/CI/SV/SvO2 What does dopamine do in medium (4-10) dose and high (11-20) dose do? Also, Levo/Neo and EPI doses? - ANSWER>>It increases everything: B/P CO/CI SVR/PVR HR PAP/RAP/PAOP