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Advanced Med Surg Exam 2 Prep
, Advanced Med Surg Exam 2
1. For the pt w/ PE, the RN should examine the chest for Petechiae
presence of after obtaining CXR and labs.
2. For the pt w/ PE, the RN should assess cardiac status Comparing
by BP in right and left arms, checking
pulse quality, checking monitor for dysrhythmias, and
checking for neck vein distention.
3. For the pt w/ PE, the RN should assess respiratory 30
status every minutes by auscultating lungs, mea-
suring rate, rhythm, and ease of respirations, check
skin color and cap refill, and check the position of the
trachea.
4. For the pt w/ PE, the RN should place the pt in high Venous
fowler position, apply telemetry monitoring equip-
ment, then obtain access after applying O2
and providing reassurance to the pt.
5. For the pt w/ PE, the RN should first apply , then O2
reassure the pt that correct measures are being taken.
6. Key features of include sudden onset of PE (pulmonary embolism)
dyspnea, pleuritic chest pain, apprehension, restless-
ness, sense of impending doom, cough, hemoptysis,
diaphoresis, increased RR, crackles, pleuritic friction
rub, tachycardia, S3/S4 sounds, low grade fever, pe-
techiae, hypoxia.
7. If PE is strongly suspected, prompt categorization and Before
management strategies are started diag-
nostic studies have been completed.
, Advanced Med Surg Exam 2
8. How should the RN respond if a PE is suspected? Call a rapid response
9. Teach pts who are traveling for long periods to drink 5
plenty of fluids, change positions often, avoid crossing
their legs, and get up from the sitting position at least
minutes out of every hour to prevent clot forma-
tion.
10. Urge pts to stop smoking cigarettes, especially Contraceptives
women who use hormone-based to
reduce the risk for VTE development.
11. Major risk factors for include prolonged im- VTE
mobility, central venous catheters, surgery, pregnan-
cy, obesity, advancing age, conditions that increase
clotting, Hx of VTE, smoking, estrogen Tx, HF, stroke,
cancer, and trauma.
12. To prevent PE, the RN should teach pts not to Cross
their legs.
13. To prevent PE, the RN teach pts to refrain from Massaging
leg muscles.
14. To prevent PE, the RN should elevate the affected limb 20
degrees or more above the level of the heart to
improve venous return as appropriate.
15. To prevent PE, the RN should perform a comprehen- 8
sive assessment of peripheral circulation every
hours.
16. Mattress