NUR 242 EXAM 2 — COMPLETE NSP REFERENCE
EVERY Action Alert ■ | Drug Alert ■ | Critical Rescue ■ — From Every Chapter in Your Action Plan
HOW TO USE: ■ Orange = Action Alert (things you must ASSESS or DO immediately) | ■ Yellow = Drug Alert (medication safety) | ■ Red =
Critical Rescue (life-threatening — ACT NOW)
UNIT 3 — Ch 13: FLUIDS & ELECTROLYTES (pp.255–268)
■ CRITICAL RESCUE — Fluid Overload — Recognize Pulmonary Edema (p.259)
Assess the patient with fluid overload at LEAST EVERY 2 HOURS to recognize pulmonary edema, which can occur very quickly and can lead to
DEATH. If signs of worsening overload are present: • Bounding pulse • Increasing neck vein distention (JVD) • Lung crackles • Increasing
peripheral edema • REDUCED URINE OUTPUT Respond by NOTIFYING the primary health care provider IMMEDIATELY. Also: Patient with
fluid overload and edema is at HIGH RISK for SKIN BREAKDOWN — use pressure-reducing mattress overlay; assess skin pressure areas
DAILY (coccyx, elbows, hips, heels).
■ ACTION ALERT — Hyponatremia — Muscle Weakness + Respiratory Check (p.260)
If MUSCLE WEAKNESS is present in a patient with hyponatremia → IMMEDIATELY check respiratory effectiveness because VENTILATION
DEPENDS ON ADEQUATE STRENGTH of respiratory muscles. The DIAPHRAGM is a muscle — hyponatremia causing muscle weakness can
impair breathing. Also: Behavioral changes, ↓LOC, and confusion result from cerebral edema and increased intracranial pressure. SUDDEN
ONSET OF ACUTE CONFUSION or INCREASED CONFUSION is often seen in OLDER ADULTS who have low serum sodium levels — report
immediately.
■ ACTION ALERT — Hypokalemia — Respiratory Assessment (p.262)
Assess respiratory status of a patient with hypokalemia AT LEAST EVERY 2 HOURS because RESPIRATORY INSUFFICIENCY and CARDIAC
DYSRHYTHMIAS are MAJOR CAUSES OF DEATH from hypokalemia. Musculoskeletal changes include skeletal muscle weakness. Patients
may be too weak to stand. Hand grasps are weak; deep tendon reflexes are reduced (hyporeflexia). Severe hypokalemia causes FLACCID
PARALYSIS. Assess muscle strength and the patient's ability to perform ADLs.
■ DRUG ALERT — IV Potassium — CARDIAC ARREST RISK (p.264)
Potassium MUST BE DILUTED for IV administration and MUST BE ADMINISTERED SLOWLY. Recommended infusion rate: 5–10 mEq/hr. ■
DO NOT GIVE POTASSIUM BY IV PUSH — this causes CARDIAC ARREST (DEATH). ■ NEVER give IV or SQ injection — potassium is a
severe tissue irritant and causes TISSUE NECROSIS. Per JOINT COMMISSION National Patient Safety Goals (NPSGs): • Concentrated
potassium must be diluted and added to IV solutions ONLY in the pharmacy by a registered pharmacist • Vials of concentrated potassium MUST
NOT be available in patient care areas • Before infusing any IV solution containing KCl — CHECK and RECHECK the dilution
■ ACTION ALERT — IV Potassium — Infiltration (p.264)
If infiltration of a solution containing potassium occurs: 1. STOP the IV solution IMMEDIATELY 2. REMOVE the venous access 3. NOTIFY the
health care provider 4. DOCUMENT these actions and provide a complete description 5. PHOTOGRAPH the IV site Potassium is caustic to
tissues — infiltration causes necrosis and loss of function of the area.
■ CRITICAL RESCUE — Hyperkalemia — Cardiac Changes (p.265)
Assess ANYONE who has or is at risk for hyperkalemia to RECOGNIZE CARDIAC CHANGES. If either of the following occurs: • Heart rate falls
BELOW 60 beats/min • T WAVES BECOME SPIKED (tall peaked T waves) → Respond by NOTIFYING THE RAPID RESPONSE TEAM
immediately. These ECG changes indicate the cardiac cells are being depolarized too easily — progression leads to V-Tach → V-Fib → cardiac
ARREST. Health teaching is key to prevention: diet, drugs, and recognition of indicators of hyperkalemia.
UNIT 3 — Ch 14: ACID-BASE BALANCE (pp.277–283)
■ CRITICAL RESCUE — Acidosis — Cardiovascular Assessment FIRST (p.277)
Assess the CARDIOVASCULAR SYSTEM FIRST in any patient at risk for acidosis because acidosis can lead to CARDIAC ARREST from the
accompanying HYPERKALEMIA. If cardiac changes are present (bradycardia, heart block, tall T waves, widened QRS, hypotension, thready
pulses) → respond by REPORTING THESE CHANGES IMMEDIATELY to the health care provider. Cardiac arrest from hyperkalemia is the
most life-threatening complication of acidosis.
, UNITS 4/5 — Ch 27-28: CARDIAC ASSESSMENT & DYSRHYTHMIAS (pp.650–681)
■ ACTION ALERT — Sinus Tachycardia — Assess for Consequences (p.668)
For patients with sinus tachycardia, assess for: • Fatigue, weakness, shortness of breath, orthopnea • DECREASED oxygen saturation •
Increased pulse rate • DECREASED blood pressure • Restlessness and anxiety (from decreased CEREBRAL perfusion) • Decreased urine
output (from impaired RENAL perfusion) • Anginal pain and palpitations • ECG: T-wave inversion or ST-segment elevation/depression (indicates
myocardial ischemia) The desired outcome is to identify and treat the UNDERLYING CAUSE of the tachycardia.
■ ACTION ALERT — Pacemakers — Patient Teaching Priority (p.672)
Teach patients who have permanent pacemakers to: • AVOID sources of strong electromagnetic fields (magnets, telecommunications
transmitters) — may change pacemaker settings or cause malfunction • MRI is usually CONTRAINDICATED — check with cardiologist based
on device model • Carry pacemaker ID card AND wear medical alert bracelet AT ALL TIMES • Take pulse for 1 full minute DAILY and record in
diary • Report: dizziness, HICCUPS (lead displacement), fainting, chest pain, weight gain • Keep cell phone ≥6 inches from device • Airport
security — device will trigger metal detector; show ID card • Stay away from arc welding equipment
■ DRUG ALERT — Adenosine — Emergency Equipment Ready (p.672)
Side effects of adenosine include SIGNIFICANT BRADYCARDIA WITH PAUSES, nausea, and vomiting. When administering adenosine → be
sure to have EMERGENCY EQUIPMENT READILY AVAILABLE! Adenosine works very briefly (half-life of seconds) but can cause prolonged
pauses in some patients.
■ ACTION ALERT — Atrial Fibrillation — Pulmonary Embolism Risk (p.673)
The loss of coordinated atrial contractions in atrial fibrillation (A-Fib) can lead to POOLING OF BLOOD → clotting → PULMONARY EMBOLISM
RISK! Thrombi may form within the RIGHT ATRIUM → move through the right ventricle → to the LUNGS. If pulmonary embolism is suspected: •
REMAIN WITH THE PATIENT • Monitor for: shortness of breath, chest pain, and/or hypotension • INITIATE THE RAPID RESPONSE TEAM •
NOTIFY the provider immediately Also: Patient is at risk for STROKE from clots traveling to the brain. Anticoagulation 4–6 weeks before AND
after cardioversion is required.
■ DRUG ALERT — Anticoagulant Drugs — Bleeding Teaching (p.677)
Teach patients taking ANY type of anticoagulant drug (warfarin, heparin, DOACs) to REPORT IMMEDIATELY: • Bruising (unusual or
unexplained) • Bleeding nose or gums • Blood in urine (pink, red, dark) • Black tarry stools (melena) • Prolonged bleeding from cuts • Coughing
or vomiting blood • Sudden severe headache • Any other signs of bleeding Report ALL bleeding signs to primary health care provider
IMMEDIATELY.
■ CRITICAL RESCUE — Cardioversion — Safety Before Shock Delivery (p.674)
BEFORE cardioversion: • TURN OXYGEN OFF and REMOVE from patient — FIRE could result from O2 + electrical shock! • Shout "CLEAR"
before shock delivery for electrical safety • Ensure all personnel step back from patient and bed AFTER cardioversion: • Assess patient's
response and heart rhythm immediately • If condition deteriorates into V-Fib after cardioversion → CHECK that synchronizer is TURNED OFF so
immediate DEFIBRILLATION can be administered • Repeat therapy if needed until desired result is obtained
■ ACTION ALERT — PVCs — Assess for Pulse + MI Warning (p.680)
Because other dysrhythmias can also cause widened QRS complexes, ASSESS WHETHER premature complexes are perfusing to the
extremities: • Palpate the carotid, brachial, or femoral arteries WHILE observing the monitor for widened complexes OR while auscultating apical
heart sounds With ACUTE MYOCARDIAL INFARCTION (MI): PVCs may be considered a WARNING that could trigger life-threatening: •
Ventricular tachycardia (VT) • Ventricular fibrillation (VF) Report new or worsening PVCs in an MI patient IMMEDIATELY.
■ CRITICAL RESCUE — Ventricular Tachycardia (VT) — ASSESS FOR PULSE FIRST! (p.681)
In some patients, ventricular tachycardia (VT) causes cardiac arrest. ASSESS FIRST: • Circulation and airway • Breathing • Level of
consciousness • Oxygenation level FOR STABLE PATIENT WITH SUSTAINED VT (has pulse): • Administer oxygen • Confirm rhythm via
12-lead ECG • Amiodarone or lidocaine may be ordered • SYNCHRONIZED cardioversion if hemodynamically unstable FOR PULSELESS VT: •
Call CODE → CPR → UNSYNCHRONIZED DEFIBRILLATION → epinephrine → amiodarone Note: If patient has been taking digoxin, withhold
up to 48 hours BEFORE elective cardioversion (digoxin increases ventricular irritability during cardioversion).
Ch 29: HEART FAILURE (pp.692–707)
EVERY Action Alert ■ | Drug Alert ■ | Critical Rescue ■ — From Every Chapter in Your Action Plan
HOW TO USE: ■ Orange = Action Alert (things you must ASSESS or DO immediately) | ■ Yellow = Drug Alert (medication safety) | ■ Red =
Critical Rescue (life-threatening — ACT NOW)
UNIT 3 — Ch 13: FLUIDS & ELECTROLYTES (pp.255–268)
■ CRITICAL RESCUE — Fluid Overload — Recognize Pulmonary Edema (p.259)
Assess the patient with fluid overload at LEAST EVERY 2 HOURS to recognize pulmonary edema, which can occur very quickly and can lead to
DEATH. If signs of worsening overload are present: • Bounding pulse • Increasing neck vein distention (JVD) • Lung crackles • Increasing
peripheral edema • REDUCED URINE OUTPUT Respond by NOTIFYING the primary health care provider IMMEDIATELY. Also: Patient with
fluid overload and edema is at HIGH RISK for SKIN BREAKDOWN — use pressure-reducing mattress overlay; assess skin pressure areas
DAILY (coccyx, elbows, hips, heels).
■ ACTION ALERT — Hyponatremia — Muscle Weakness + Respiratory Check (p.260)
If MUSCLE WEAKNESS is present in a patient with hyponatremia → IMMEDIATELY check respiratory effectiveness because VENTILATION
DEPENDS ON ADEQUATE STRENGTH of respiratory muscles. The DIAPHRAGM is a muscle — hyponatremia causing muscle weakness can
impair breathing. Also: Behavioral changes, ↓LOC, and confusion result from cerebral edema and increased intracranial pressure. SUDDEN
ONSET OF ACUTE CONFUSION or INCREASED CONFUSION is often seen in OLDER ADULTS who have low serum sodium levels — report
immediately.
■ ACTION ALERT — Hypokalemia — Respiratory Assessment (p.262)
Assess respiratory status of a patient with hypokalemia AT LEAST EVERY 2 HOURS because RESPIRATORY INSUFFICIENCY and CARDIAC
DYSRHYTHMIAS are MAJOR CAUSES OF DEATH from hypokalemia. Musculoskeletal changes include skeletal muscle weakness. Patients
may be too weak to stand. Hand grasps are weak; deep tendon reflexes are reduced (hyporeflexia). Severe hypokalemia causes FLACCID
PARALYSIS. Assess muscle strength and the patient's ability to perform ADLs.
■ DRUG ALERT — IV Potassium — CARDIAC ARREST RISK (p.264)
Potassium MUST BE DILUTED for IV administration and MUST BE ADMINISTERED SLOWLY. Recommended infusion rate: 5–10 mEq/hr. ■
DO NOT GIVE POTASSIUM BY IV PUSH — this causes CARDIAC ARREST (DEATH). ■ NEVER give IV or SQ injection — potassium is a
severe tissue irritant and causes TISSUE NECROSIS. Per JOINT COMMISSION National Patient Safety Goals (NPSGs): • Concentrated
potassium must be diluted and added to IV solutions ONLY in the pharmacy by a registered pharmacist • Vials of concentrated potassium MUST
NOT be available in patient care areas • Before infusing any IV solution containing KCl — CHECK and RECHECK the dilution
■ ACTION ALERT — IV Potassium — Infiltration (p.264)
If infiltration of a solution containing potassium occurs: 1. STOP the IV solution IMMEDIATELY 2. REMOVE the venous access 3. NOTIFY the
health care provider 4. DOCUMENT these actions and provide a complete description 5. PHOTOGRAPH the IV site Potassium is caustic to
tissues — infiltration causes necrosis and loss of function of the area.
■ CRITICAL RESCUE — Hyperkalemia — Cardiac Changes (p.265)
Assess ANYONE who has or is at risk for hyperkalemia to RECOGNIZE CARDIAC CHANGES. If either of the following occurs: • Heart rate falls
BELOW 60 beats/min • T WAVES BECOME SPIKED (tall peaked T waves) → Respond by NOTIFYING THE RAPID RESPONSE TEAM
immediately. These ECG changes indicate the cardiac cells are being depolarized too easily — progression leads to V-Tach → V-Fib → cardiac
ARREST. Health teaching is key to prevention: diet, drugs, and recognition of indicators of hyperkalemia.
UNIT 3 — Ch 14: ACID-BASE BALANCE (pp.277–283)
■ CRITICAL RESCUE — Acidosis — Cardiovascular Assessment FIRST (p.277)
Assess the CARDIOVASCULAR SYSTEM FIRST in any patient at risk for acidosis because acidosis can lead to CARDIAC ARREST from the
accompanying HYPERKALEMIA. If cardiac changes are present (bradycardia, heart block, tall T waves, widened QRS, hypotension, thready
pulses) → respond by REPORTING THESE CHANGES IMMEDIATELY to the health care provider. Cardiac arrest from hyperkalemia is the
most life-threatening complication of acidosis.
, UNITS 4/5 — Ch 27-28: CARDIAC ASSESSMENT & DYSRHYTHMIAS (pp.650–681)
■ ACTION ALERT — Sinus Tachycardia — Assess for Consequences (p.668)
For patients with sinus tachycardia, assess for: • Fatigue, weakness, shortness of breath, orthopnea • DECREASED oxygen saturation •
Increased pulse rate • DECREASED blood pressure • Restlessness and anxiety (from decreased CEREBRAL perfusion) • Decreased urine
output (from impaired RENAL perfusion) • Anginal pain and palpitations • ECG: T-wave inversion or ST-segment elevation/depression (indicates
myocardial ischemia) The desired outcome is to identify and treat the UNDERLYING CAUSE of the tachycardia.
■ ACTION ALERT — Pacemakers — Patient Teaching Priority (p.672)
Teach patients who have permanent pacemakers to: • AVOID sources of strong electromagnetic fields (magnets, telecommunications
transmitters) — may change pacemaker settings or cause malfunction • MRI is usually CONTRAINDICATED — check with cardiologist based
on device model • Carry pacemaker ID card AND wear medical alert bracelet AT ALL TIMES • Take pulse for 1 full minute DAILY and record in
diary • Report: dizziness, HICCUPS (lead displacement), fainting, chest pain, weight gain • Keep cell phone ≥6 inches from device • Airport
security — device will trigger metal detector; show ID card • Stay away from arc welding equipment
■ DRUG ALERT — Adenosine — Emergency Equipment Ready (p.672)
Side effects of adenosine include SIGNIFICANT BRADYCARDIA WITH PAUSES, nausea, and vomiting. When administering adenosine → be
sure to have EMERGENCY EQUIPMENT READILY AVAILABLE! Adenosine works very briefly (half-life of seconds) but can cause prolonged
pauses in some patients.
■ ACTION ALERT — Atrial Fibrillation — Pulmonary Embolism Risk (p.673)
The loss of coordinated atrial contractions in atrial fibrillation (A-Fib) can lead to POOLING OF BLOOD → clotting → PULMONARY EMBOLISM
RISK! Thrombi may form within the RIGHT ATRIUM → move through the right ventricle → to the LUNGS. If pulmonary embolism is suspected: •
REMAIN WITH THE PATIENT • Monitor for: shortness of breath, chest pain, and/or hypotension • INITIATE THE RAPID RESPONSE TEAM •
NOTIFY the provider immediately Also: Patient is at risk for STROKE from clots traveling to the brain. Anticoagulation 4–6 weeks before AND
after cardioversion is required.
■ DRUG ALERT — Anticoagulant Drugs — Bleeding Teaching (p.677)
Teach patients taking ANY type of anticoagulant drug (warfarin, heparin, DOACs) to REPORT IMMEDIATELY: • Bruising (unusual or
unexplained) • Bleeding nose or gums • Blood in urine (pink, red, dark) • Black tarry stools (melena) • Prolonged bleeding from cuts • Coughing
or vomiting blood • Sudden severe headache • Any other signs of bleeding Report ALL bleeding signs to primary health care provider
IMMEDIATELY.
■ CRITICAL RESCUE — Cardioversion — Safety Before Shock Delivery (p.674)
BEFORE cardioversion: • TURN OXYGEN OFF and REMOVE from patient — FIRE could result from O2 + electrical shock! • Shout "CLEAR"
before shock delivery for electrical safety • Ensure all personnel step back from patient and bed AFTER cardioversion: • Assess patient's
response and heart rhythm immediately • If condition deteriorates into V-Fib after cardioversion → CHECK that synchronizer is TURNED OFF so
immediate DEFIBRILLATION can be administered • Repeat therapy if needed until desired result is obtained
■ ACTION ALERT — PVCs — Assess for Pulse + MI Warning (p.680)
Because other dysrhythmias can also cause widened QRS complexes, ASSESS WHETHER premature complexes are perfusing to the
extremities: • Palpate the carotid, brachial, or femoral arteries WHILE observing the monitor for widened complexes OR while auscultating apical
heart sounds With ACUTE MYOCARDIAL INFARCTION (MI): PVCs may be considered a WARNING that could trigger life-threatening: •
Ventricular tachycardia (VT) • Ventricular fibrillation (VF) Report new or worsening PVCs in an MI patient IMMEDIATELY.
■ CRITICAL RESCUE — Ventricular Tachycardia (VT) — ASSESS FOR PULSE FIRST! (p.681)
In some patients, ventricular tachycardia (VT) causes cardiac arrest. ASSESS FIRST: • Circulation and airway • Breathing • Level of
consciousness • Oxygenation level FOR STABLE PATIENT WITH SUSTAINED VT (has pulse): • Administer oxygen • Confirm rhythm via
12-lead ECG • Amiodarone or lidocaine may be ordered • SYNCHRONIZED cardioversion if hemodynamically unstable FOR PULSELESS VT: •
Call CODE → CPR → UNSYNCHRONIZED DEFIBRILLATION → epinephrine → amiodarone Note: If patient has been taking digoxin, withhold
up to 48 hours BEFORE elective cardioversion (digoxin increases ventricular irritability during cardioversion).
Ch 29: HEART FAILURE (pp.692–707)
