NUR 242 Exam 4 With Complete Solution Graded A+

NUR 242 Exam 4 With Complete Solution Graded A+ Normal BP - Systolic 120 / Diastolic 80 Pre-HTN - Systolic =120-139 / Diastolic=80-89 Stage 1 HTN - Systolic=140-159 / Diastolic=90-99 Stage 2 HTN - Systolic=160 / Diastolic=100 Malignant HTN - Extremely high BP 180/110 S/S of Malignant HTN - initially asymptomatic, headache upon awakening, blurred vision, dizziness, chest pain, difficult breathing, numbness in face and legs, tinnitus, flushed face, epistaxis HTN Crisis - acute and life threatening; accelerated HTN requires ER treatment because organ damage can occur quickly Pharmacological interventions for HTN - ACE Inhibitors, Diuretics, Calcium Channel Blockers, ARBs, and Beta Blockers What symptom should you report right away with ACE Inhibitors? - Dry nagging cough- discontinue immediately and teach about orthostatic HTN in elderly What is an example of an ACE inhibitor drug? - Lisinopril, Enalapril What is an example of a Calcium Channel Blocker? - Verapamil, Amlodopine What is an example of an ARB? - Losartan, Valsartan What is an example of a Beta Blocker? - Metoprolol, Atenolol Pt. teaching for Raynauds disease - Stop smoking, avoid cold and stress, wear warm clothing, take vasodilators as prescribed Pt. teaching for Burgers Disease - Use vasodilators as prescribed, smoking cessation, avoid injury to upper and lower extremities, can cause gangrene S/S of Peripheral Arterial Disease (PAD) - Leg pain, burning, cramping muscle discomfort when walking that stops at rest. As the disease persists the pt can walk shorter distances Post-OP Care for Femoral Artery Bypass graft? - warmth, redness and edema are expected. Monitor for possible occlusion and continuous aching pain (first sign of occlusion) Throbbing pain is due to increased blood flow to the area. Notify the physician immediately if they experience what S/S after a femoral artery graft? - Cold, pale, cyanotic skin or decreased pulse Amputation complications: - infection, phantom limb pain, flexion contractions Amputation Post-OP care: - -DO NOT elevate limb on pillow (can cause flexion contractures) -1st 24 hours elevate the foot of the bed to decrease edema then keep the bed flat -24-48 hours- place the pt. in prone position to stretch muscles and prevent hip flexion contractures Pt with a DVT is at high risk for? - PE DVT S/S - -calf/groin tenderness -sudden unilateral swelling -positive Homans sign DVT Risk Factors - -venous stasis from varicose veins -heart failure -immobility -use of birth control -ulcerative colitis -prolonged bedrest DVT interventions: - -SCDs -Compression hose -Elevate extremities -IV continuous Heparin When a pt. is on IV continuous Heparin, what lab values do you monitor? - aPTT Values What is the normal aPTT range? - 30-40 seconds 1.5-3 times normal control levels *Call the MD if 70 seconds* Normal PT level: - 11-12.5 seconds -1.5-2.5 times normal control level when on Coumadin Normal PTT level: - 60-70 seconds -1.5-2.5 times the normal control on Heparin Normal INR level: - 0.9-1.2 seconds Miserable therapeutic level is 2-3 times the normal Normal total cholesterol level: - 140-199 Normal LDL level: - 130 Normal HDL level: - 30-70 Normal triglyceride level: - 200 Where do you listen for the Aortic sound? - 2nd Intercostal space, RSB Where do you listen for the Pulmonic sound? - 2nd intercostal space, LSB Where do you listen for Erbs Point? - 3rd intercostal space, LSB Where do you listen to the Tricuspid? - 4th intercostal space, LSB Where do you listen to the Mitral sound? - 5th intercostal space, mid-clavicular line What is the only sound heard on the RSB? - Aortic Pre-OP teaching for Cardiac Cath - -Might experience palpitations when the catheter is passed through the left ventricle -Feel heat or hot flash when the dye is injected -Urge to cough when the dye is injected to the RIGHT side of the heart Post-OP for Pacemaker - -Report fever, redness, swelling or drainage to MD -Keep ID card in wallet or wear medical alert bracelet -Know rate of pacemaker -Avoid tight clothing What symptoms do you report to the MD if you have a pacemaker? - -SOB -Dizziness -Chest Pain -Fainting -Weight gain -Hiccups (Check pulse at time of incident for any of these) S/S of RIGHT sided heart failure - -Dependent edema -JVD -Abdominal distention -Hepatomegaly -Splenomegaly -Anorexia/nausea -Weight gain -Nocturnal diuresis -Swelling of fingers/hands What lab values are used to confirm heart failure? - BNP S/S of Pulmonary Edema: - -Severe dyspnea or orthopnea -Pallor -Tachycardia -Tachypnea -Expectoration of blood tinged frothy sputum -Wheezing/ crackles in the lungs -Anxiety -Nasal flaring -Use of accessory muscles S/S of Bradycardia: - -Confusion -Syncope (fainting) -Dizziness -Weakness -Hypotension -SOB -Angina Bradycardia treatment: - Atropine, epi, dopamine, IV fluids, O2 S/S of V-Tach: - -Angina -Syncope (fainting) -Light headedness -Dizziness -SOB V-Tach Treatment: - -O2 -Confirm with 12 lead EKG -Mag Sulfate -Lidocaine -Amiodarone S/S of V-Fib: - -fainting/loss of consciousness -no pulse -no breathing -no BP or heart sounds Within minutes pupils become fixed and dilated, skin cold and mottled V-Fib treatment: - -DEFIBRILATION IS PRIORITY! -Do CPR until defib is available