when should heparin infusion be discontinued? - ANS INR MAINTAIN 2-3
-warfarin doses are adjusted to maintain the INR at 2-3 then heparin should be discontinued
self care for pt with peripheral arterial disease - ANS EXERCISE DAILY FOR AT LEAST 30 MINUTES; INSPECT FEET AND ANKLE...
when should heparin infusion be discontinued? - ANS INR MAINTAIN 2-3
-warfarin doses are adjusted to maintain the INR at 2-3 then heparin should be discontinued
self care for pt with peripheral arterial disease - ANS EXERCISE DAILY FOR AT LEAST 30
MINUTES; INSPECT FEET AND ANKLESS DAILY FOR INJURIES
Meds for MI in addition to percutaneous coronary intervention - ANS ASPIRIN AND
CLOPIDOGREL
-aspirin and antiplatelet therpay with clopidogrel reduces mortality in clients with MI and should
be admin to all clients with an acute MI regardless of reperfusion therapy
a pt with severe tearing chest pain with early diastolic decrescendo murmur and blood pressure
is measured on both arms and shows a 30 mmHg difference between the left and right arm and
ECG shows ST elevation in anteriolateral leads, WHAT SHOULD NURSE DO - ANS
PREPARE FOR EMERGENCY SURGERY
-pt is expericing AORTIC DISSECTION (acute on set of chest pain with a tearing feel, inter arm
BP differnce greater than 20 and early diastolic decrescendo) so EMERGENCY SURGICAL
EXPLORATION AND GRAFTING IS REQUIRED TO PREVENT DEATH
PT pacemaker insertion site begins to bleed what should nurse assess pt for> - ANS
DISSEMINATED INTRAVSULAR COAGULATION
-when a healing site starts to slowly ooze blood this is an indication of clotting malfunction which
is manifestation of disseminated intravascular coagulation
what to do after while one nurse is giving CPR on a pt with dilated cardiopyopathy ventricular
fibrillation - ANS ADMINISTER EPINEHRINE
-after defib and CPR, second nurse should INITIATE VASOPRESSOR THERPAY WITH
EPINEPHRINE 1MG EVERY 3-5 TO INCREASE CORONARY PERFUSION PRESSURE AND
ENHANCE SURVIVAL
What to do first for pt with mobitz II secondary AV block appears anxious ans SOB with a slow
heart rate and low blood pressure? - ANS START TRANSCUTANUOUS PACING
-when a pt demonstrates AV block the nurse should start trasncutaneous pacing
, what does the UAP do wrong when they are helping a pt with indwelling cath and jackson pratt
bulb drain after a right nephrectomy earlier that day? - ANS REPLACE CATH BAG AND
PLACES ON THE BED ON THE CLIENTS RIGHT SIDE
-placing the cath bad on the bed increases the risk of urinanry tract infections
a pt with obstructive sleep apnea that still feels fatigue after 8 hrs of sleep and shows ABGs of
decreased O2 and increased Co2 overnight, what should the nurse do? - ANS
DEMONSTRATE THE USE OF A POSTIVE AIRWAY PRESSURE DEVICE
-the client with untreated sleep apnea would benefit of postive pressure airway pressure and
provide teaching onthe importance
Treatment for acute respiratroy distress syndrome - ANS s/s= sob, low oxygen levels,
cough, fever, tachycardia, tachypnea, chest pain, and cyanosis of the lips and nails beds
TX: PLACE PT IN PRONE POSITION ; ADMIN FURSOMIDE (removes extra fluid)
a pt cardiac tracing has atrial rhythm 70 bpm, regular, ventricular rate 60 bpm, and regular
irregular; P wave morphology normal progressive lengthing of the PR interval until one P wave
is not conducted; QRS morphology is normal, the nurse finds that the pt is asymptonmatic what
should they dO? - ANS DOCUMENT FINDINGS AND CONTINUE MONITORING
-the cardiac monitor is showing a second degree AV block, Mobitz type I and is considered
benign bc it does not progress to complete heart block
a pt has abdominal ultrasound shows bilateral hyronephrosis what is underlying cause of this
condition? - ANS BENIGN PROSTATIC HYPERPLASIA
-BPH compresses the urethra, resulting in impaired bladder empyting and if there is severe
constriciton the pt will experience vesiculo-ureteral reflux that leads bilateral hyronephrosis of
the kidneys
what is a normal pr interval - ANS 0.12-0.20
a pt with a hx of multiple small bowel resections for Crohn's disease is experiencing increased
brusing, what nutrient deficiency are they experiencing? - ANS VITAMIN K
-because of the multiple surgies for tx of Crohn's disese the client may have malabsorption of
vitamin K in the small bowel; THIS VITAMIN IS NEEDED FOR BLOOD CLOTTING
Neurogenic shock - ANS -the loss of sympathetic tone, massive vasodilation takes place,
with blood pooling in the extremitis and vascular beds= HYPOTENSION AND WARM
EXTREMITIS DUE TO INCREASED PERIPHERAL CIRCULATION AND BRADYCARDIA
FROM UNOOPOSED VAGAL ACITIVTY
EX: Hr 48, BP 70/45, warm extremities
if a nurse hears the first korotoff sounds when the sphygonanometer shoes 115 mmhg during
expiration and 90 mmhg during inspiration what should the nurse do? - ANS AUSCULTATE
THE CLIENT'S HEART
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