NCLEX UWorld CARDIOVERSION
Abdominal Aortic Aneurysm - ANS-ENLARGEMENT OF AORTA AT LEVEL OF
ABDOMEN
-surgery done in cath lab (graft)
-after surgery watch groin puncture sites, peripheral pulses, UO, kidney function
-tx: stent graft (noninvasive) or synthetic graft (invasive)
-graft leakage sx: ecchymosis of groin, increased abdominal girth, tachycardia, weak or
absent peripheral pulses, decreasing H&H, decreased urinary output
-rupture or tear may present as acute abdominal pain radiating to back
Abdominal Surgery - ANS--absent bowel sounds expected 24-48 hours after surgery
-peristalsis will usually return to SI in 24 hrs but LI may be delayed 3-5 days
Active Seizure Interventions - ANS--remain at bedside
-call for help
-pad side rails
-turn client on side
-loosen clothing around neck and chest
-use suction equipment after seizure subsides
Acute Pancreatitis - ANS-SUDDEN INFLAMMATION OF THE PANCREAS
-sx: upper abdominal pain radiating to back, swollen/tender abdomen, n/v, fever
-management: NPO status, pain mgmt, IV fluids
Addison's Disease - ANS-ADRENAL INSUFFICIENCY
-sx: bronze hyperpigmentation of skin, patchy/blotchy skin, slow progressive onset of
fatigue/weakness, anorexia and weight loss, orthostatic hypotension,
hyponatremia/hyperkalemia, salt cravings, n/v, depression & irritability
-Addison's crisis: hypotension & tachycardia, dehydration, hyperkalemia/hyponatremia,
hypoglycemia, fever, weakness, confusion
Age-Related Macular Degeneration - ANS-GRADUAL LOSS OF CENTRAL VISION
Air Embolism - ANS-BLOCKAGE OF BLOOD SUPPLY CAUSED BY AIR BUBBLE IN
VESSEL
,-rare complication of central venous catheters (if becomes dislodged apply occlusive
dressing, administer O2 via non-rebreather, place in left lateral trendelenburg position,
monitor VS, notify HCP)
Allergy Testing - ANS--AVOID antihistamines & corticosteroids prior to testing
Alzheimer's Disease - ANS-DEGENERATIVE DISEASE
-depending on client's current symptoms teach family about safety
-communication teaching: use distraction & redirection, speak slowly with simple words
and yes/no questions, do not try to rationalize with client, use visual cues when giving
directions, interact with client as an adult, break down complex activities into simple
steps with simple instruction, limit number of choices to decrease anxiety
-if ANY confusion is present keep medications away from patient
-cx: genetic, lifestyle, environmental factors (smoking, excessive alcohol intake,
exercising regularly, participate in mentally challenging activities), age > 65
Amputation - ANS--residual limb should not be elevated especially after 24 hour
-manage edema with figure eight compression bandage and placement in prone
position for 30 minutes 3-4 times per day
-wash with soap and warm water
-watch for s/s infection
-perform daily ROM
-avoid potential irritants (strong soaps, lotion)
Amyotrophic Lateral Sclerosis (ALS) - ANS-PROGRESSIVE DEGENERATION OF
MOTOR NEURONS
-no cure
-progressive degeneration of motor neurons
-sx: fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty
swallowing, difficulty speaking, respiratory failure
-clients survive only 3-5 years after diagnosis
-treatment focuses on sx management
Anaphylactic Shock - ANS-SYSTEMIC LIFE THREATENING ALLERGIC REACTION
-acute onset (20-30 minutes)
,-management: stop infusion and call for help, assess airway and apply oxygen, IM epi
(repeat in 5-15 minutes if no response), adjunctive therapies
(bronchodilators/antihistamines/corticosteroids), continue to assess VS for changes
Angina Pectoris - ANS-CHEST PAIN BROUGHT ON BY MYOCARDIAL ISCHEMIA
-causes (increase oxygen demand): physical exertion, intense emotion, temperature
extremes, tobacco use, stimulants (cocaine/amphetamines), coronary artery narrowing
Aortic Dissection - ANS-TEAR IN INNER LINING OF AORTA
-priority before surgery is decreasing risk of aortic rupture by maintaining normal
pressure in the aorta (ex. administer IV beta blocker)
Aortic Stenosis - ANS-NARROWING OF AORTIC VALVE WHICH OBSTRUCTS
BLOOD FLOW FROM LEFT VENTRICLE
-the heart cannot overcome worsening obstruction
-loud ejection systolic murmur on auscultation
-may require aorta replacement
Aphasia/Dysphasia
1. receptive
2. expressive - ANS-1. impairment or loss of language comprehension
-encourage independence
-ask short, simple yes/no questions
-use gestures or pictures
-remain patient and calm allowing time to understand the instruction
2. impairment or loss of ability to speak
Appendicitis - ANS-INFLAMMATION OF APPENDIX
-fluid resuscitation PRIORITY
-surgical removal
ARDS - ANS-FLUID FILLS ALVEOLI INHIBITING GAS EXCHANGE
-refractory hypoxemia (increased oxygen does not increase O2 level)
-positive pressure ventilation or intubation may be necessary
, Assessing Need for Spinal Immobilization - ANS-N-neurological examination
(numbness and decreased strength)
S-significant trauma
A-alertness
I-intoxication
D-distracting injury
S-spinal examination
Asthma Attack - ANS-ACUTE SEVERE BRONCHIOLITIS USUALLY BROUGHT ON BY
SPECIFIC TRIGGERS
-accessory respiratory muscle use
-chest tightness
-cough
-diminished breath sounds
-high pitched expiratory wheezing
-tachypnea
-treat with albuterol
Asystole - ANS--no electrical activity
-CPR & OXYGEN
-defibrillation not indicated d/t no electrical impulse of heart
-client with have no pulse or respirations and will be unresponsive
-life support measures necessary
Atrial Fibrillation - ANS-HEART'S UPPER CHAMBERS BEAT TOO QUICKLY AT AN
IRREGULAR RATE
-common dysrhythmia after cardiac surgery
-risk for clots in atria resulting in stroke
-tx: control rate (ca ch blockers, beta blockers, digoxin), maintain sinus rhythm
(amiodarone, flecainide, sotalol), electrical cardioversion
Atrial Flutter - ANS-HEART'S UPPER CHAMBERS BEAT TOO QUICKLY AT A
REGULAR RATE
-recurring, regular, saw-tooth shaped flutter waves
