Comprehensive HESI Review Exit Test Bank 2022/2023 (Over 2000 Questions and Answers)

Comprehensive HESI Review Exit Test Bank 2022/2023 (Over 2000 Questions and Answers) Acute Respiratory Distress Syndrome (ARDS) The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body's cells Characteristics of ARDS Hypoxemia that persists even when 100% oxygen is given; decreased pulmonary compliance; dyspnea; non-cardiac associated bilateral pulmonary edema; dense pulmonary infiltrates on X-ray ARDS No abnormal breath sounds are present in this disorder on auscultation because the edema occurs first in the interstitial spaces and not the airways. ARDS Unexpected, catastrophic pulmonary complication occurring in a person with no pervious pulmonary problems. ARDS Common laboratory finding is a lowered pO2; not responsive to high concentrations of oxygen and often need intubation and mechanical ventilation with PEEP PEEP Positive end-expiratory pressure The instillation and maintenance of small amounts of air into the alveolar sacs to prevent then from collapsing each time the client exhales; amount of pressure can be set and is usually around 5-10cm of water Nursing Assessment of ARDS Dyspnea, hyperpnea; intercostals retractions; cyanosis, pallor; hypoxemia; diffuse pulmonary infiltrates seen on chest radiograph as "white-out" appearance; verbalized anxiety, restlessness Hypoxemia PO2 50mmHg with FiO2 60% Common causes of respiratory failure COPD; pneumonia; tuberculosis; contusion; aspiration; inhaled toxins' emboli; drug OD; fluid overload; DIC; shock Suction When providing care to a patient with ARDS, only do this when secretions are present 7.35-7.45 PH normal value 35-45 mmH PCO2 normal value 22-26 mEq HCO3 normal value 80-100mm PO2 normal value 95-100% O2 normal value Allen Test Perform this test before drawing an ABG from the radial artery Common cause of respiratory failure in children Congenital heart disease; respiratory distress syndrome; infection, sepsis; neuromuscular diseases; trauma and burns; aspiration; fluid overload and dehydration; anesthesia and narcotic OD Nursing assessment of child in respiratory failure Kid just "looks bad;" very slow or very rapid RR, dyspnea, apnea, gasping; tachycardia; cyanosis, pallor, or mottled color; irritability and lethargy; retractions, nasal flaring, poor air movement; hypoxemia, hypercapnia, respiratory acidosis Respiratory Failure PCO2 45 or PO2 60 on 50% O2; a child in severe distress should be on 100% O2 Shock Widespread, serious reduction of tissue perfusion which, if prolonged, leads to generalized impairment of cellular functioning System Hypotension Marked reduction in either cardiac output or peripheral vasomotor tone, without a compensatory elevation in the other results in this Early signs of shock Agitation and restlessness that results from cerebral hypoxia Hypovolemic Shock Related to external or internal blood or fluid loss Cardiogenic Shock Related to ischemia or impairment in tissue perfusion resulting from MI, serious arrhythmia, or HF; all cause decrease CO Vasogenic Shock Related to allergens, spinal cord injury, or peripheral neuropathies, all resulting in venous pooling and decreased blood return to the heart, which decreases cardiac output over time Septic Shock Related to endotoxins released by bacteria, which cause vascular pooling, diminished venous return, and reduced CO High fowler position with legs down Position to reduce venous return in order to decrease further venous return to the left ventricle Medical treatment for shock Rapid infusion of volume-expanding fluids such as whole blood, plasma, plasma substitutes; isotonic, electrolyte IV solutions; CVP artery catheters; CVP measurements, urine output, HR, clinical and mental state; immediate attendtion to improvement of perfusion; administration of drugs is withheld until circulating volume has been restores; O2 administration Pulmonary edema If shock is cardiogenic in nature, the infusion of volume-expanding fluids may result in this Cardiac Function When treating a patient with shock, the restoration of what should take priority Increase Cardiac Contractility Administration of cardiotonic drugs such as digitalis does what? Dopamine and digitalis Increases the contractility Dopamine (Dopram) and norepinephrine (Levophed) Vaso-constricting agents that may be used in cardiogenic shock Nursing Assessment of patient in shock Tachycardia, tachypnea, decrease in BP (systolic 80mmHg) ; mental status changes; cool, clammy skin; diaphoresis, paleness; urine output decreases; CVP 4cm of H2O; urine SG 1.020 Hypovolemia Urine SG 1.020 indicates? Early shock mental status changes Restless, hyper-alert Late shock mental status changes Decreased alertness, lethargy, coma Patient in shock Maintain a urine output of at least 30ml/hr and notify health care provider if it drops below this CVP Administer prescribed fluids until designated ?? is reached in patients with shock CVP When a patient is in shock, this number is usually elevated to 16-19 cm of H2O as compensation for decreased cardiac output Patient in shock Place this patient in Trendelenburg position (feet up 45 degrees, head flat IM or Subcutaneous route Do not administer medications via these routes to a patient in shock until perfusion improves to the muscles and subcutaneous tissues Vasopressors or adrenergic stimulants When administering these medications to a patient in shock, they must be administered via a volume-controlled pump; monitor BP q 5-15 min; watch IV site carefully for extravasation and tissue damage; ask about the target mean systolic BP Vasopressors or adrenergic stimulants used in shock patients Epinephrine (Bronkaid). Dopamine (Dopram), Dobutamine (Dobutrex), norepinephrine (Levophed), isoproterenol (Isuprel) Vasodilators used in shock patients Hydralazine (Apresoline), nitroprusside (Nipride), labetalol hydrochloride (Normodyne, Trandate) Vasopressor and vasodilator drugs Potent drugs used in shock patients; dangerous and require that the client be weaned onto and off them. Don't change both infusions rates simultaneously. Vasodilator; Vasopressor If drop in BP occurs, decrease ?? infusion rate first, then increase ?? rate Vasopressor; Vasodilator If BP increases, decrease ?? rate first, then increase the rate of the ?? Stage 1 of hypovolemic shock Initial stage; blood loss of less than 10%; compensatory mechanisms triggered; apprehension and restlessness; increased HR; cool, pale skin; fatigue; arteriolar constriction; increased production of ADH; arterial pressure maintained; CO normal; reduction in blood flow to the skin and muscle beds Stage 2 of Hypovolemic Shock Compensatory stage; blood volume reduced by 15%-25%; decompensation begins; flattened neck veins and delayed venous filling time; increased HR&RR; pallor, diaphoresis and cool skin; decreased UP; sunken soft eyeballs; confusion; marked reduced in CO; arterial pressure decline; massive adrenergic compensatory response; decrease cerebral perfusion massive adrenergic compensatory response Tachycardia, tachypnea, cutaneous vasoconstriction and oliguria Stage 3 of Hypovolemic shock Progressive stage; edema; increased blood viscosity; excessively low BP; dysrhythmia, ischemia, and MI; weak, thread, or absent peripheral pulses; rapid circulatory deterioration; decreased CO; decreased tissue perfusion; reduced blood volume Stage 4 of Hypovolemic shock Irreversible stage; profound hypotension that is unresponsive to vasopressor drugs; severe hypoxemia that is unresponsive to O2; anuria, renal shut down; HR slows, BP falls with consequent cardiac and respiratory arrest; cell destruction so severe that death is inevitable; multiple organ system failure Severe shock Leads to widespread cellular injury and impairs the integrity of the capillary membranes Fluid and osmotic proteins Seep into the extravascular spaces, further reducing CO Mean arterial pressure Normal value in adults 100mmHg Mean arterial pressure Level of pressure in the central arterial bed measured indirectly by BP; measured directly through arterial catheter insertion MAP calculation CO x total peripheral resistance = systolic BP + 2/3 Cardiac Output Volume of blood ejected by the left ventricle per unit of time Cardiac output Normal value is 4-6L/min CO calculation Stroke volume (amount of blood ejected per beat) x HR Peripheral resistance Resistance to blood flow offered by the vessels in the peripheral vascular bed. Central venous pressure Pressure within the right atrium Central venous pressure Normal values are between 4-10cm H2O Packed RBC Less danger of fluid overload; used for acute blood loss Frozen RBCs Prepared from RBCs using glycerol for protection and then frozen Frozen RBCs Must be used within 24 hours of being thawed; used as an auto transfusion; infrequently used because filters remove most of the WBCS Platelets pooled 300mL; one unit contains single donor (200mL) Platelets Bag should be agitated periodically; used for bleeding caused by thrombocytopenia Fresh frozen plasma Liquid portion of whole blood is separated from cells and frozen Fresh frozen plasma The use of this is being replaced by albumin plasma expanders; used for bleeding caused by deficiency in clotting factors Albumin Prepared from plasma and is available in 5% and 20% solutions Albumin 25g/100mL is osmotically equal to 500mL of plasma; used for hypovolemic shock and hypoalbuminemia Cryoprepcipitates and commercial concentrates Prepared from fresh frozen plasma with 10-20mL/bag Cryoprepcipitates and commercial concentrates Used in treated hemophilia; replacement of clotting factors, especially factor VII and fibrinogen Acute hemolytic Chills, fever, low back pain, flushing, tachycardia, hypotension pressing to acute renal failure, shock and cardiac arrest Nursing interventions for acute hemolytic Reaction STOP TRANSFUSION; change tubing, then continue saline IV; treat for shock; draw blood samples for serologic testing; monitor UOP hourly; give diuretics Febrile nonhemolytic reaction Most common blood transfusion reaction; sudden chills and fever, headaches, flushing, anxiety, and muscle pain Febrile nonhemolytic reaction nursing interventions Give antipyretics Mild allergic reaction Flushing, itching, hives (urticaria) Mild allergic reaction nursing interventions Give antihistamine Anaphylactic and severe allergic reaction Anxiety, uricaria, wheezing progressive cyanosis leading to shock and possible cardiac arrest Anaphylactic and severe allergic reaction nursing interventions Initiate CPR Magnesium sulfate CNS depressant administered to a preeclamptic client to prevent seizures, may be used as a tocolytic to stop preterm labor contractions; adverse reactions: CNS depression: depressed RR, depressed DTRs, decreased urine output, pulmonary edema; hold if RR 12 or urine output 100ml/4hr; DTRs absent; monitor levels; therapeutic range 5-8mg/dl; remind client of warm, flushed feeling with IV administration; keep calcium gluconate antidote Magnesium toxicity RR12, urine output 100ml/4hr, absent DTRs, levels 8mg/dl Tachycardia Major side effect of terbulatine (brethine) and ritodrine (yutopar); used to stop preterm labor; withhold if pulse 120-140 Fentanyl citrate (Sublimaze) Used as an adjunct to anesthesia; adverse reactions: respiratory depression, apnea, bradycardia, hypotension; have resuscitation equipment readily available; don't mix with IB barbiturates Morphine sulfate Often first choice for severe pain; adverse reactions: NV, constipation, respiratory depression, depression of cough reflexes, hypotension; chest RR and BP before administration; have narcan available just incase Ampicillin (ampicin, ampilean) Broad-spectrum antibiotic used to treat postpartum endometritis, mastitis; adverse reactions: rash, dermatitis, NV, GI irritation; don't administer to clients with penicillin; does appear in breast milk but may not cause neonate discomfort Gentamicin sulfate (garamycin) Indication: aminoglycoside antibiotic used for serious puerperal infections; adverse reactions: GI irritation, nephrotoxicty, ototoxicity, neurotoxicity, possible hypersensitivity; don't mix with any other drug; observe fro ototoxicity, ataxia, tinnitus, headache, nephrotoxicitym elevated BUN and creatinine, neurotoxicity, parenthesia, muscle weakness, I&O closely Sodium bicarbonate Indicated for correction of severe metabolic acidosis in asphyxiated infants after adequate ventilation begun; adverse reaction: fluid overload, hypernatremia, intracranial hemorrhage; don't mix with calcium solutions; pediatric concentration; infuse slowly and monitor I&O; newborn resiscitation Epinephrine Indicated for asystole or severe bradycardia; adverse reactions: tachyarrhythmias; make sure ventilation of newborn is adequate, do not inject directly into artery; monitor apical pulse or connect to ECG before use Circulatory overload Cough, dyspnea, pulmonary congestion, headache, hypertension Circulatory overload nursing interventions Place client in upright position with feet in dependent position and administer diuretics, O2 and morphine Sepsis Rapid onset of chills, high fever, vomiting, marked hypotension, or shock Sepsis nursing interventions Ensure patent airway, obtain blood for culture, administer prescribed antibiotics, take VS q 5 min Nursing skills for blood transfusion Use central venous catheter or 19 gauge needle; only use blood administration tubing; run blood products with saline only; check and double check product before infusing - correct product, correct blood type and RH factor What to do if patient in shock arrives at the hospital Maintain patent airway; keep client warm and free of constricting clothing; keep clients legs elevated Epinephrine 1:1000, 0.2-0.5mL SUBCU for mild shock cases Epinephrine 1:10,000; 5mL IV for severe cases of shock Volume expanding drugs Usually given to patients in shock Drugs of choice for shock Digitalis and vasoconstrictors preparations Digitalis preparations Increase contractility of the heart muscle Levophed, Dompamine (vasoconstrictors) Provides more blood to the heart to help maintain cardiac output Disseminated intravascular clotting (DIC) A coagulation disorder with paradoxic thrombosis and hemorrhage DIC Acute complication of conditions such as hypotention and septicemia; suspected when there is bloody oozing from two or more unexpected sites. DIC First phase involves abnormal clotting in the microcirculation, which uses up clotting factions and results in the inability to form clots, so hemorrhage occurs DIC diagnosis Prothrombin time (PT): prolonged; partial thromboplastim time (PTT): prolonged; fibrinogen: decreased; platelet count: decreased; fibrin degradation products: increased DIC nursing assessment Petechiae, purpura, hematomas; oozing from IV sites, drains, gums and wounds; GI and GU bleeding; hemoptysis; mental status changes; hypotension, tachycardia; pain DIC nursing intervention Administer heparin IV during first phase to inhibit coagulation Heparin Blocks the formation of thrombin Care of a patient with DIC - hemorrhage stage Administration of clotting factors, palliative treatment of the symptoms Cardiopulmonary arrest Necrosis of the heart muscle aused by inadequate blood supply to the heart; usually caused by MI; MI's usually occur at rest or with moderate activity Symptoms immediately preceding MI Chest pain or discomfort at rest or with ordinary activity; change in previous angina pain; increase in frequency in CP or severity or rest angina; chest pain in a client with known coronary heart disease that is unrelieved by rest of nitroglycerin Cardiopulmonary arrest O2 is necessary for survival Chest pain Described as crushing, pressing, constricting, oppressive or heavy; increase in intensity for a few minutes; substernal or more diffused; may radiate to one or both shoulders and arms or to neck, jaw or back When to seek emergency medical services The symptoms of anterior myocardial infarction characteristically last more than 15 minutes and are more intense than angina; if chest discomfort worsens or is unimproved 5 minutes after taking one tablet of spray of nitro. Management of cardiac arrest unwitnessed; out of hospital Position person supine, tap and call out are you okay?; no response = call for help, ask someone to call 911, obtain AED; extend neck with head-tilt, chin-lift; assess breathing sounds by look-listen-feel method; no breathing is noted = ventilate with 2 mouth-mouth breaths, assess circulation by palpating carotid pulse; no pulse = compressions at 100/min CPR Performed at a 30:2 ratio of compression to ventilations; after 5 phases, reassess for breathing and pulse 20 weeks pregnant and beyond CPR Shift the gravid uterus to the left by placing the woman in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left In hospital cardiac arrest No response, call a code; position on cardiac board; ventilate with O2 mask; initiate chest compressions; apply cardiac monitor "quick look" paddles to determine whether defibrillation is necessary; resume CPR after defibrillation Defibrillation Indicated in ventricular fibrillation or pulseless ventricular tachycardia Bicarbonate Not to be used unless hyperkalemia, tricyclic antidepressant overdose, or preexisting metabolic acidosis is documented Neonatal resuscitation Ventilations are done over the mouth and nose; palpate brachial pulse in infant 1 years; HR under 60 = compressions are done with thumbs side by side over the lower third of the sternum; compression to ventilation ratio of 3:1 (90 compressions; 30 breaths) Child 1-8 resuscitation