A client recovering from a percutaneous coronary intervention (PCI) after an acute myocardial
infarction is being transferred from the PACU to the Cardiac ICU. Which assessment finding
should the PACU nurse inform the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay - ANSa. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
What is the preferred treatment of an acute MI within 12 hours of symptom onset? - ANSPCI;
places a stent in the affected coronary artery
How often must a PCI pressure dressing site be assessed? - ANSq30min for 4 hours
qh thereafter
Central Venous Pressure (CVP) - ANSthe pressure of blood in the thoracic vena cava, near the
right atrium of the heart; reflects the amount of blood returning to the heart and the ability of the
heart to pump the blood into the arterial system; normal is 2-6 mmHg
Sensitivity of a pacemaker - ANSpacing devices ability to detect what electrical activity is being
generated by the patient's heart to prevent any competition between the hearts intrinsic activity
Contrast Induced Nephropathy (CIN) - ANSA sudden deterioration in renal function that is
caused by intravascular administration of iodinated contrast medium; typically seen with
angiplasty/angiography
Signs of tension pneumothorax - ANS1. affected side will have decreased or absent lung
sounds
2. cyanosis
3. Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
Pneumatic Antishock Garment - ANSAn inflatable device that covers the legs and abdomen;
used to splint the lower extremities or pelvis, or to control bleeding in the lower extremities or
pelvis.
- used for intraperitoneal hemorrhage
What is the expected ABG of a pulmonary embolism? - ANSTachypnea and tachycardia-->
respiratory alkalosis
, A client is brought to the emergency department following a motor vehicle accident. Initial
assessment reveals that the client is unconscious with a blood pressure of 165/73 mmHg, HR
50 bpm, RR 8 and irregular, temperature of 103 F. What do you suspect is happening? -
ANSThe findings reveal Cushing's Triad (hypertension with widening pulse pressure,
bradycardia and bradypnea); this indicates increased ICP
Symptoms of Right Ventricular Hypertrophy - ANSfatigue, swelling, weakness, chest pain, SOB,
dizziness
The nurse is caring for a client who is being weaned from mechanical ventilation. Which
assessment finding indicates that the client is ready to the the endotracheal tube removed? -
ANS- pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure
-PEEP <8 and FiO2 <0.50
- hemodynamic stability
- ability to initiate an inspiratory effort.
A client with ARDS was endotracheally intubated and transferred to the ICU 12 hours ago. Upon
assessment, the nurse notes bilateral rales and diminished breath sounds in the right middle
lobe and bilateral lower lobes, as well as bluish nail beds. Based on the client's presentation,
which actions should be taken? - ANS- Place the patient in prone position
- administer prescribed Lasix
Pulmonary Capillary Wedge Pressure - ANSplaced in the pulmonary artery to indirectly measure
left atrial pressure; 4-12
Norepinephrine (Levophed) - ANS- Uses: treatment of severe hypotension and shock
-MOA: increase blood pressure and cardiac output by stimulating alpha-adrenergic receptors in
the blood vessels to cause *vasoconstriction*
Sodium Nitroprusside (Nitropress) - ANSVery potent vasodilator
*drug of choice for hypotensive emergencies
- nitrO--> vessels dilate like the O
The nurse suspects that a client with ESKD has developed uremic syndrome. What did the
nurse assess to support this clinical determination? - ANSpericardial friction rub; increased
bleeding; hepatic encephalopathy, asterixis, peripheral neuroapthy
Neurological degeneration of upper and lower motor neurons resulting in muscle atrophy,
fasciculations, hyperreflexia and spasticity is called: - ANSAmyotrophic Lateral Sclerosis
When should stomas be emptied? - ANSbefore meals or 2 hours after eating
infarction is being transferred from the PACU to the Cardiac ICU. Which assessment finding
should the PACU nurse inform the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay - ANSa. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
What is the preferred treatment of an acute MI within 12 hours of symptom onset? - ANSPCI;
places a stent in the affected coronary artery
How often must a PCI pressure dressing site be assessed? - ANSq30min for 4 hours
qh thereafter
Central Venous Pressure (CVP) - ANSthe pressure of blood in the thoracic vena cava, near the
right atrium of the heart; reflects the amount of blood returning to the heart and the ability of the
heart to pump the blood into the arterial system; normal is 2-6 mmHg
Sensitivity of a pacemaker - ANSpacing devices ability to detect what electrical activity is being
generated by the patient's heart to prevent any competition between the hearts intrinsic activity
Contrast Induced Nephropathy (CIN) - ANSA sudden deterioration in renal function that is
caused by intravascular administration of iodinated contrast medium; typically seen with
angiplasty/angiography
Signs of tension pneumothorax - ANS1. affected side will have decreased or absent lung
sounds
2. cyanosis
3. Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
Pneumatic Antishock Garment - ANSAn inflatable device that covers the legs and abdomen;
used to splint the lower extremities or pelvis, or to control bleeding in the lower extremities or
pelvis.
- used for intraperitoneal hemorrhage
What is the expected ABG of a pulmonary embolism? - ANSTachypnea and tachycardia-->
respiratory alkalosis
, A client is brought to the emergency department following a motor vehicle accident. Initial
assessment reveals that the client is unconscious with a blood pressure of 165/73 mmHg, HR
50 bpm, RR 8 and irregular, temperature of 103 F. What do you suspect is happening? -
ANSThe findings reveal Cushing's Triad (hypertension with widening pulse pressure,
bradycardia and bradypnea); this indicates increased ICP
Symptoms of Right Ventricular Hypertrophy - ANSfatigue, swelling, weakness, chest pain, SOB,
dizziness
The nurse is caring for a client who is being weaned from mechanical ventilation. Which
assessment finding indicates that the client is ready to the the endotracheal tube removed? -
ANS- pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure
-PEEP <8 and FiO2 <0.50
- hemodynamic stability
- ability to initiate an inspiratory effort.
A client with ARDS was endotracheally intubated and transferred to the ICU 12 hours ago. Upon
assessment, the nurse notes bilateral rales and diminished breath sounds in the right middle
lobe and bilateral lower lobes, as well as bluish nail beds. Based on the client's presentation,
which actions should be taken? - ANS- Place the patient in prone position
- administer prescribed Lasix
Pulmonary Capillary Wedge Pressure - ANSplaced in the pulmonary artery to indirectly measure
left atrial pressure; 4-12
Norepinephrine (Levophed) - ANS- Uses: treatment of severe hypotension and shock
-MOA: increase blood pressure and cardiac output by stimulating alpha-adrenergic receptors in
the blood vessels to cause *vasoconstriction*
Sodium Nitroprusside (Nitropress) - ANSVery potent vasodilator
*drug of choice for hypotensive emergencies
- nitrO--> vessels dilate like the O
The nurse suspects that a client with ESKD has developed uremic syndrome. What did the
nurse assess to support this clinical determination? - ANSpericardial friction rub; increased
bleeding; hepatic encephalopathy, asterixis, peripheral neuroapthy
Neurological degeneration of upper and lower motor neurons resulting in muscle atrophy,
fasciculations, hyperreflexia and spasticity is called: - ANSAmyotrophic Lateral Sclerosis
When should stomas be emptied? - ANSbefore meals or 2 hours after eating
