Exam 1

Question 1

Risk Factors of dehydration: causes of Hypovolemia

Answer 1

Excessive gastrointestinal (GI) loss: V/D, nasogastric suctioning
Excessive skin loss: diaphoresis (w/o Na & H2O replacement)
Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency
Third spacing: burns
Hemorrhage or plasma loss
Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO (decrease intake of Na & H2O)

Question 2

Causes of Dehydration

Answer 2

⊛ Hyperventilation or excessive perspiration without water treatment
⊛ Prolonged fever
⊛ DKA
⊛ Insufficient intake (enteral feeding w/o water admin, decreased thirst sensation, aphasia)
⊛ Diabetes Insipidus
⊛ Osmotic Diuresis
⊛ Excessive intake of salt, salt tablets, or hypertonic IV fluids

Question 3

Dehydration Assessment Findings

Answer 3

⊛ Vitals: Hypothermia, tachycardia (attempt to maintain BP), thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia
⊛ Neuro: dizziness syncope, confusion, vomiting, anorexia, acute weight loss
⊛ GI: thirst, dry furrowed tongue, N/V, anorexia, acute weight loss
⊛ Renal: Oliguria (decreased production and concentration of urine)
⊛ Other Findings:
- diminished cap refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, poor skin turgor and tenting
- effect is greater in older adults due to loss of elasticity of skin, decrease in glomerular filtration and concentration ability of the kidneys, loss of muscle mass, and diminished thirst reflex
- pt may have elevated temp (cause or finding)
- rapid/seizure dehydration can induce seizures

Question 4

Dehydration Interventions

Answer 4

⊛ Provide oral or IV rehydration therapy
⊛ Monitor I&O
⊛ Monitor vitals (ortho hypo, HR)
⊛ Monitor for changes in mentation and confusion (an indication of worsening fluid imbalance)
⊛ Monitor weight every 8hr while fluid replacement is in progress
assess level of gait stability. Encourage the client to use call light and ask for assistance because of the increased risk for falls
⊛ Encourage the client to change positions, rolling from side to side or standing up slowly
⊛ Collaborate with healthcare team to determine appropriate fluid volume replacement and oxygen management

Question 5

Dehydration Patient Teaching

Answer 5

Drink plenty of liquids to promote hydration
Causes of dehydration include: V/D, large draining wounds, or excessive stony losses

Question 6

Dehydration Outcome Evaluation

Answer 6

Maintains a daily fluid intake of at least 1500mL (or drinks at least 500mL more than daily output)
Maintains BP at or near their normal range
Has moist mucous membranes and normal skin turgor
Asks for assistance when ambulating
Does not fall
Can state the indications of dehydration
Starts fluid replacement at the first indication of dehydration
Correctly follows treatment plans for ongoing health problem that increase the risk of dehydration

Question 7

Hypokalemia Assessment Findings

Answer 7

Assessment: K+ Lab Value= <3.5
⊛ Vitals: decreased BP
Thready weak pulse, orthostatic hypotension
⊛ Neuro: altered mental status, anxiety, and lethargy that progresses to acute confusion and coma
⊛ ECG: Flattened T wave, prominent U waves, ST depression, prolonged PR interval
⊛ GI: Hypoactive bowel sounds, N/V constipation, abdominal distention, paralytic ileum can develop
⊛ Muscular: weakness, diminished deep tendon reflexes
⊛ Resp: shallow breathing
⊛ Older adults are more susceptible: decreased urine concentration leads to potassium loss, as well as taking drugs that lead to potassium loss
⊛ Disease can lead to potassium loss ask about chronic disorders and recent illnesses
⊛ Diuretics, Corticosteroids, Beta-agrenergic, Agonists or Antagonists
can increase renal potassium loss
⊛ Ask about potassium supplements or foods high in potassium (bananas, citrus juice raisins, and meat)
⊛ My have no symptoms if loss is gradual, dramatic function changes if loss is rapid

Question 8

Hypokalemia Interventions

Answer 8

⊛ Ensure adequate gas exchange, prevent pt falls, prevent injury from potassium admin, monitor response to therapy, monitor breathing effectiveness, and increase serum potassium
⊛ Drug therapy: additional potassium and drugs to prevent potassium loss
- IV potassium for severe hypokalemia
- Potassium is a sever tissue irritant, never give IM or SC
⊛ Have pt eat potassium rich foods

Question 9

Hyperkalemia Assessment

Answer 9

Assessment: K+ Lab Value= >5.0
Cardiac= palpitations, skipped heart beats or other cardiac irregularities, bradycardia, hypotension
ECG= tall, peaked T waves, prolonged PR intervals, flat or absent P waves, wide QRS complexes, ectopic beats may appear, complete heart block, systole, and v-fib
Neuromuscular= skeletal muscles twitches (early stages), tingling burning sensations, followed by numbness in the hands and feet and around the mouth (paresthesia), (as progresses) muscle weakness, followed by flaccid paralysis (muscle weakness moves up from hands and feet and first affects arm and leg muscles)
Respiratory= muscles are unaffected until serum K+ levels reach lethal levels
GI= increased motility with diarrhea (BM frequent and watery), and hyperactive bowl sounds

Question 10

Hyperkalemia Interventions

Answer 10

Reduce serum potassium level
Prevent recurrence
Ensure patient safety
Drug Therapy: restore potassium balance through excretion and movement of potassium
Cardiac monitoring

Question 11

Hyponatremia Assessment

Answer 11

Assessment: Na Lab Value=<135
Very low= seizure, coma, death
Cardio= changing in cardiac output, rapid, weak, thready pulse, peripheral pulses difficult to palpate and easily blocked, BP decreased, may have severe ortho hypo leading to severe dizziness and lightheadedness, central venous pressure low
Cardio changes with hypervolemia= bounding pulses, normal/high BP, peripheral pulses full and difficult to block (may not be palpable if edema is present)
Cerebral changes: cerebral edema and increased intracranial pressure, causes behavioral changes, alter LOC and cognition, sudden onset of acute confusion or increased confusion (often seen in older adults)
Neuromuscular= muscle weakness(worse in arms and legs), diminish deep tendon reflex
GI= increased motility causing nausea, diarrhea (BM frequent and watery), and abd cramping, hyperactive bowl sounds

Question 12

Hyponatremia Interventions

Answer 12

Drug Therapy: reduce any drugs that increase sodium loss such as diuretics
- Fluid deficit: IV saline infusion to restore sodium and fluid volume
- Fluid excess: drugs that promote the excretion of water rather than sodium
Nutrition Therapy: restores sodium balance in mild hyponatremia: fluid restrictions (may be need for long term)

Question 13

Hypernatremia Assessment:

Answer 13

Assessment: Na Lab Value= >145
Nervous System= altered cerebral function, (w normal or decreased fluid volumes) short attention span, agitation/ confusion, (fluid overload) lethargic, stuporous, or comatose
Skeletal muscle= mild rises/early stages= muscle twitching irregular muscle contractions; as it worsens muscles become progressively weaker; late stages= reduced/absent deep tendon reflexes
Caardio= decreased contractibility; hypovolemia= HR increased, peripheral pulses difficult to palpate and are easily blocked, pulse pressure reduces, hypotension, severe ortho hypo; hypervolemia= slow/normal bounding pulses, JVD distended (even in upright position) BP increased

Question 14

Hypernatremia Interventions

Answer 14

Drug Therapy: used tor restore fluid balance when hypernatremia caused by fluid loss
- isotonic saline (0.9% NaCl), Dextrose 5% in 0.45% NaCl
Nutrition therapy: used to ensure adequate water intake
- dietary sodium restriction may be needed

Question 15

Hypocalcemia Assessment

Answer 15

Assessment: Ca Lab Value= <9.0
Tests: Trousseau’s sign (BP cuff/1-4mins), Chvostek’s sign (tape side of face)
Cardio= HR slower/faster, weak/thready pulse, sever hypotension
ECG= prolonged ST and QR intervals
Neuromuscular= weakness, paresthesia (tingling & numbness), muscle twitching, painful cramping, severe spasms, tingling may affect lips, nose and ears (problems may signal inset of neuromuscular overstimulation and tetany)
GI= increased activity, hyperactive bowel sounds, painful abd cramping and diarrhea
skeletal= osteoporosis, bones are less dense, more brittle and fragile, may break easily w slight trauma, vertebrae become more compact and spin may bend forward, leading to overall loss of height

Question 16

Hypocalcemia Interventions

Answer 16

• Restore normal calcium levels
  Drug Therapy: direct calcium replacement (PO or IV), along with Vitamin D
  Nutrition Therapy: calcium rise foods
  Reduce environmental stimuli prevent injury

Question 17

Hypercalcemia Assessment

Answer 17

Assessment: Ca Lab Value= >10.5
Cardio= mild: increased HR and BP, severe: dressed electrical conduction, slowed HR, measure pulse rate and BP, observe for indications of poor perfusion (cyanosis/pallor), measure/record calf circumference w soft tape measure, assess feet temp, color and cap refill
ECG= dysrhythmias, shortened QT interval
Neuromuscular= severe muscle weakness, decreased deep tendon reflex w/o paresthesia, may be confused lethargic
GI= decreased peristalsis, constipation, anorexia, N/V, abd distention and pain, hypoactive bowel sounds, assess abd size by measuring girth w soft tape measure in a life circling the abdomen at the umbilicus

Question 18

Hypercalcemia Interventions

Answer 18

Reduce calcium levels
Drug Therapy: stop IV solutions and oral drugs containing calcium, stop vitamin D
- Rehydration: fluid volume replacement e.g. IV NS
- Diuretics that help excrete calcium
- Drugs to prevent hypercalcemia
- Possible dialysis and cardiac monitoring

Question 19

Hypomagnesemia Assessment

Answer 19

Assessment: Mg Lab Value= < 1.3
Tests= Positive Trousseau and Chvostek signs
Cardio= increased risk of hypertension, atherosclerosis, hypertrophic L ventricle, and variety of dysrhythmias (premature contractions, a-fib, v-fib, associated with greater cardiac muscle cell damage after MI
ECG= long QT intervals, shortened ST segment, prolonged PR and QRS intervals, and triggering ectopic beats
Neuromuscular= hyperactive deep tendon reflexes, numbness, tingling, and painful muscle contractions, as worsens pt may have tetany and seizuresGI= decreased intestinal smooth muscle contraction, reduced motility, anorexia nausea, constipation and abd distention, if severe paralytic ileus

Question 20

Hypomagnesium Interventions

Answer 20

Correct imbalance
Manage the specific problem that caused hypomagnesemia
Drug Therapy: drugs promoting magnesium loss discontinued, magnesium sulfate given IV w sever hypomagnesemia

Question 21

Hypermagnesium Assessment

Answer 21

Assessment: Mg Lab Value= >2.1
Cardio=bradycardia peripheral vasodilation, hypotension, cardiac arrest
ECG= prolonged PR interval w widened QRS complex
CNS= drowsy, lethargic, coma
Neuromuscular= reduced/absent deep tendon reflexes, voluntary muscle contractions become progressively weaker and then stop
Resp= has no direct affect on lungs however if lung muscles are weak, respiratory insufficiency can lead to resp failure and death

Question 22

Hypermagnesium Intervention

Answer 22

Reduce serum level
Correct underlying problem
Oral and parenteral magnesium discontinued
Magnesium-free IV fluids
Loop Diuretics

Question 23

Fluid Overload Priority Care/Interventions

Answer 23

Monitor I&Os, daily weight (weight gain.loss of 1kg/day=1L), assess breath sounds, monitor for peripheral edema, maintain sodium restriction diet as prescribed, maintain fluid restriction if prescribed, encourage rest, monitor client, monitor pt receiving diuretics, position client in semi-fowler’s/ fowler’s position, and reposition to prevent tissue breakdown in edematous skin, use a pressure-reducing mattress and assess bony prominences, monitor blood sodium and potassium levels
Respiratory services can be consulted for oxygen management
Pulmonology can be consulted if fluid moves in the lungs

Question 24

Fluid Volume Excess Expected Findings

Answer 24

Vital Signs= tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
Neuromuscular= weakness, visual changes, altered LOC, seizures
GI= ascites, increased motility, liver enlargement
Resp= crackles, cough, dyspnea
Other signs= peripheral edema due to excess fluid in body and lungs, resulting in weight gain, distended JVD, increased urine output, skin cool to touch with pallor
Lab Test= Decreased H&H, blood osmolarity, urine sodium and urine specific gravity, BUN due to plasma dilution

Question 25

Respiratory Acidosis

Answer 25

pH= <7.35 PaCO2= >45 HCO3-= 22-26

Question 26

Metabolic Acidosis

Answer 26

pH= <7.35 PaCO2= 35-45 HCO3-= <22

Question 27

Respiratory Alkalosis

Answer 27

pH= >7.45 PaCO2= <35 HCO3-= 22-26

Question 28

Metabolic Alkalosis

Answer 28

pH= >7.45 PaCO2= 35-45 HCO3-= >26

Question 29

Respiratory Acidosis Assessment (Hypoventilation)

Answer 29

Increase CO2, increased/normal H+ concentration Vitals= initial tachycardia and hypotension, as worsens, bradycardia and hypotension Dysrhythmias= V-fib Neuro= initial anxiety, irritability, and confusion, lethargy and possible coma Resp= ineffective, shallow, rapid breathing Skin= pale/cyanotic Seen in pt with pulmonary disease, sleep apnea and obesity

Question 30

Respiratory Acidosis Interventions

Answer 30

Drug therapy (bronchodilators and mucolytics), oxygen therapy, maintain patent airway and enhance gas exchange (positioning and breathing techniques), ventilatory support, prevent complications

Question 31

Metabolic Acidosis Assessment

Answer 31

Decreased HCO3- and increased H+ concentration Vitals: bradycardia, weak peripheral pulses, hypotension, tachypnea Neuro= headache, drowsiness, confusion Respiratory= Rapid, deep respirations (Kussmaul respirations) Skin= warm, dry, pink

Question 32

Metabolic Acidosis Interventions

Answer 32

Varies with causes DKA= administer insulin GI losses= administer antidiarrheal and provide rehydration, if blood bicarb is low, admin sodium bicarb 1mEq/kg

Question 33

Respiratory Alkalosis Assessment (Hyperventilation)

Answer 33

Decreased CO2, decreased/normal H+ concentration Vitals: tachypnea Neuro: inability to concentrate, numbness tingling, tinnitus, and possible loss of consciousness Cardio= tachycardia, ventricular and atrial dysrhythmias Resp= rapid and deep

Question 34

Respiratory Alkalosis Intervention

Answer 34

Oxygen Therapy, anxiety reduction interventions and rebreathing techniques

Question 35

Metabolic Alkalosis Assessment

Answer 35

increased HCO3-, decreased H+ Vitals: tachycardia, normotensive or hypotensive Dysrhythmias: atrial tachycardia, ventricular issues when pH increases Neuro: numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion, convulsion resp: Depressed skeletal muscles, resulting in ineffective breathing

Question 36

Metabolic Alkalosis Interventions

Answer 36

Varies with cause, GI losses= admin antiemetics, fluids, and electrolyte replacements, if related to K+ depletion, discount ue causative agent

Question 37

Peripheral IV Site Considerations

Answer 37

Within peripheral vessels, 26-guage (smallest) to 14-gauge (largest), Rotate sites based on clinical indications Avoid areas of joint flexion Choose most distal site possible Avoid dominant side if possible Do NOT use side of mastectomy, AV Fistula, lymph node dissection or paralysis Limit unsuccessful attempts to 2 per clinician Use sterile technique and monitor for Cather-related blood stream infections

Question 38

Central IV site Considerations

Answer 38

Vascular access device (VAD) placed in central circulation, specifically within superior vena cava (SVC) near junction with right atrium Chest x-ray is done to confirm placement Newer technologies (magnet tip locator, electrocardiogram) can also be used to detect placement Must be placed by specifically certified person Use sterile technique and monitor for Central line-related blood stream infections

Question 39

Local complications for peripheral IV site

Answer 39

Phlebitis Infiltration/Extravasation Thrombosis Site Infection

Question 40

Site Infection

Answer 40

Infection at insertion point, port pocket or subcutaneous tunnel Clinical Manifestations: Site is red, swollen, warm Potential purulent or odoris exudate Interventions/Prevention: Clean exit site, remove catheter, send for culture, cover with dry sterile dressing; Aseptic technique, Hand hygiene

Question 41

Thrombosis

Answer 41

Blood clot within vein Clinical Manifestations: Swollen extremity, Tenderness/redness, Slowed/stopped infusion Interventions/Prevention: Stop infusion, apply cold compress Elevate extremity, Potential need for surgical intervention; Use EBP Venipuncture techniques

Question 42

Infiltration

Answer 42

Leakage of non-vesicant solution into tissues surrounding the vein Clinical Manifestations: Skin is cool, tight, tender, Fluid leaking from puncture site Interventions/Preventions: Stop Infusion, remove site, Elevate extremity, Cold/Warm Compress; Stabilize catheter Avoid pressure on/near site – restraints/BP cuffs Assess frequently

Question 43

Extravasation

Answer 43

Leakage of vesicant solution Clinical Manifestations: In addition to those associated with infiltration, Blistering/tissue sloughing Interventions/Prevention: Stop infusion, Surgical intervention may be necessary; Stabilize catheter, Avoid pressure on/near site – restraints/BP cuffs, Assess frequently

Question 44

Phlebitis

Answer 44

Inflammation of the vein Clinical Manifestations: Pain at sight, Skin is red, inflamed, potentially hard Interventions/Prevention: Remove site if possible, Heat and elevate extremity; Choose smallest gauge possible, Avoid areas of flexion

Question 45

Infiltration From Peripheral IV Site Treatment

Answer 45

Stop infusion and remove short peripheral catheter immediately after identification of problem Apply sterile dressing is weeping from tissue occurs Elevate Extremity Warm/cold compress (warm: improve circulation and healing; cold: reducing pain and swelling) Insert new catheter in opposite extremity Rate the infiltration using the INS infiltration scale and document

Question 46

Central Venous Access Device Client Teaching

Answer 46

Education for prevention of CRBSI Before insertion educate about: type of catheter, hand hygiene and aseptic technique for care of catheter and therapy, the therapy required, alternatives to the catheter and therapy, activity limitations, any s/s report immediately Provide written information

Question 47

Priority action for a client with HF taking Digoxin, causing adverse effects

Answer 47

Monitor apical pulse rate and heart rhythm (>70bpm risk for increased mortality), report any changes in rhythm Monitor serum digoxin and potassium levels (hypokalemia potentiates dig tox) Older adults are more likely to develop dig tox due to decreased renal excretion Any drug increasing workload of failing heart, also increase O2 requirement, be alert for angina in response to dig Toxic digoxin levels or presence of hypokalemia= Increased cardiac automaticity, resulting in ectopic beats (e.g. premature ventricular contractions (PVCs)) Its with changes in potassium level (especially decrease) causes pt to be more sensitive to the drugs and cause toxicity S/S of digoxin toxicity: vague and nonspecific; anorexia, fatigue, blurred vision, and changes in mental status (especially in older adults), nearly any dysrhythmia (PVCs most commonly noted) Early S/S of toxicity: bradycardia, heart block, and loss of the P wave on the ECG

Question 48

Digoxin Adverse Effects

Answer 48

CNS: confusion, depression, drowsiness, extreme weakness, headache syncope CV: Arrhythmias, heart block EENT: Blurred vision, colored halos around objects GI: Abd discomfort/pain, anorexia, D/N/V Electrolyte Imbalances Use caution when pregnant and breast feeding

Question 49

Furosemide (Lasix) Adverse Effects

Answer 49

CNS: dizziness, fever, headache, lethargy, paresthesia, restlessness, vertigo, weakness CV: arrhythmia, elevated cholesterol and triglyceride levels, orthostatic hypotension, shock, tachycardia, thromboembolism, thrombophlebitis vertigo EENT: Blurred, vision, deafness, dry mouth, oral irritation, ototoxicity, stomatitis, tinnitus, hearing loss, (rapid IV injection), yellow vision ENDO: Hyperglycemia GI: azotemia, bladder spasms, glycosuria, oliguria HEME: Agranulocytosis (rare), eosinophilia, hemolytic anemia, leukopenia, thrombocytopenia MS: muscle pain/spasms SKIN: acute generalized exanthematous pustulosis, bullous pemphigoid, erythema multiform, exfoliative dermatitis, photosensitivity, pruritus purport, rash, Steve-johnson syndrome, toxic epidural necrolysis, urticaria Other: Allergic reaction/anaphylaxis, dehydration, drug reaction with eosinophilia and systemic symptoms (DRESS), hyperuricemia, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, thirst Use caution when pregnant and breastfeeding

Question 50

S/S Left-Sided HF

Answer 50

Decreased Cardiac Output: - fatigue, weakness, oliguria during the day (nocturia at night), angina, confusion/ restlessness, dizziness, tachycardia/palpitations, pallor, weak peripheral pulses, cool extremities Pulmonary Congestion: - hacking cough, worse at night; dyspnea/breathlessness; crackles or wheezes in lungs, frothy, pink-tinged sputum, tachypnea, S3/S4 summation gallop

Question 51

S/S Right-Sided HF

Answer 51

Systemic congestion, JVD, enlarged liver and spleen, anorexia and nausea, dependent edema, distended abdomen, swollen hands and fingers, polyuria at night, weight gain, increased BP (from excessive volume), decreased BP (from failure)

Question 52

MAWDS Pt Education for HF

Answer 52

M: Medications: - take med as prescribed and do not run out - know purpose and side effects of each drug - avoid NSAIDs to prevent sodium and fluid retention A: Activity: - stay as active as possible, don't overdo it - know your limits, be able to carry on a conversation while exercising W: Weight: - weigh each day same time same scale to monitor fluid retention D: Diet: - limit daily sodium intake to 2-3g as prescribed - limit daily fluid intake to 2L S: Symptoms: - note any new/worsening symptoms and notify HCP immediately

Question 53

HF Priority Interventions

Answer 53

Increase gas exchange and perfusion Reduce preload (diuretics, thiazides) Enhance contractibility (digoxin, beta-blockers, aldosterone antagonists, HCN channel blocker) Weigh patient daily Monitor for worsening condition

Question 54

Right-sided HF Interventions and Patient Education

Answer 54

Monitor daily weight and I&O Asses for SOB, and dyspnea on exertion Administer oxygen as prescribed Monitor vital signs and hemodynamic pressures Position pt to maximize ventilation (high-fowlers) Monitor diagnostic results to track progress Assess manifestations of med toxicity (dig tox) Encourage bed rest until stable Encourage energy conversation by assisting with care and ADLs Maintain dietary prescriptions as prescribed (restrict fluid and sodium intake) Provide emotional support to client and family If self administering dig: count pulse rate for 1 min before taking, if pulse is irregular or pulse rate outside of limitations set by provider (<60bpm or >100bpm), hold dose and contact provider; take does at same time each day, do not take at same time as antacids (atleast 2hr apart), report manifestations of toxicity (fatigue muscle weakness, confusion and loss of appetite); have blood digoxin and potassium levels checked regularly

Question 55

HF Priority Nursing Assessment

Answer 55

Assess ABCs and vitals Assess for depression and anxiety Assess labs values: - electrolyte imbalance - effects of drug therapy - renal function: BUN, Cr - H&H - B-type natriuretic peptide (BNP) - proteinuria/urine specific gravity - ABGs Chest X-Ray, ECG, Thallium imaging/technetium pyrophosphate scanning, Multigated acquisition (MUGA)/multigated blood pool scans Invasive hemodynamic monitoring

Question 56

Atenolol Adverse Effects

Answer 56

CNS: depression, disorientation, dizziness, drowsiness, emotional lability, fatigue, fever, lethargy, light-headedness, short-term memory loss, vertigo CV: arrhythmias, including bradycardia and heart block; cariogenic shock; cold arms and legs; mitral insufficiency, myocardial reinfarction; ortho hypo; Raynaud's phenomenon EENT: dry eyes, laryngospasm, pharyngitis GI: diarrhea, nausea, ischemic colitis, mesenteric arty thrombosis GU: renal failure HEME: agranulocytosis MS: leg pain Resp: bronchospasm, dyspnea, pulmonary emboli, resp distress, wheezing Skin: erythematous rash other: allergic reaction Use caution when progeny and breastfeeding

Question 57

Categories of BP

Answer 57

Normal= <120/<80 Prehypertensive= 120-129/<80 (or 120-139/80-89) Stage 1 HTN= 130/139/80-89 (or 140-159/90-99) Stage 2 HTN= ≥140/≥90 (or >160/>100)

Question 58

Warfarin Adverse Effects

Answer 58

CNS: coma, intracranial hemorrhage, loss of consciousness, syncope weakness CV: angina, calcium uremic arteriolopathy, chest pain, hypotension EENT: epistaxis, intraocular hemorrhage GI: abd camps/pain, D/N/V, hepatitis, jaundice GU: Hematuria, vaginal bleeding (abnormal) HEME: anemia, potentially fatal hemorrhage SKING: alopecia, ecchymosis, petechiae, pruritus, purple-toe syndorme, tissue necrosis Other: anaphylaxis

Question 59

Warfarin Contraindications/Interactions

Answer 59

- Bleeding/bleeding tendencies, cerebral or dissecting aneurysm, cerebrovascular hemorrhage, diverticulitis, eclampsia/preeclampsia, uncontrolled hypertension, malnutrition, pericardial effusion, pericarditis, history of warfarin induced necrosis, ophthalmic surgery, severe hepatic or renal disease - NSAIDS, loop diuretics, acetaminophen, erythromycin, salicylates, corticosteroids, sulfonamides, vitamin E, influenza virus vaccine, penicillins, estrogens, ahminoglycosides, beta-blockers, glucagon, thiazide diuretics, vitamin C, atorvastatin/pravastatin, herbal remedies (gingko biloba, garlic), vitamin K rich foods, nicotine patch, alcohol use, smoking

Question 60

PVD Interventions

Answer 60

Prevent/treat VTE: Encourage ambulation after anticoagulation therapy initiated, Warm moist compress, Do NOT massage affected limb Venous Insufficiency interventions: Avoid crossing legs, Elevate legs for 20min, 4-5/day, Elevate legs above heart when in bed Treat Varicose Veins: 3 E's: Elastic compression hose, exercise and elevation Medications: - Anticoagulants (Heparin (Monitor PTT), Lovenox, Coumadin (Monitor INR), Eliquis, Xarelto) - Antiplatelets (ASA, Plavix) - Thrombolytic (Heparin, Lovenox)

Question 61

PAD Assessment Findings

Answer 61

- Six P's: Pain, Pallor (pale appearance), Pulselessness, Paresthesia (numbness), Paralysis (loss of movement), Poikilothermia (coolness) - Intermittent Claudication: Burning, cramping pain in legs during exercise - Numbness/burning sensation in feet when in bed: Pain relief when in dependent position - Decreased capillary refill - Decreased/Non-palpable pulses - Loss of hair on lower calf, ankle, foot - Dry, scaly, mottled skin - Thick toenails - Cold and cyanotic extremity - Pallor of extremity with elevation - Rubor (redness) of extremity - Ulcers: End of Toes or Between Toes, Pale with little granulation

Question 62

Nitroglycerin Tablet Administration

Answer 62

- instruct pt to lie down when taking (hypotensive response can be dramatic) - take every 5 mins for pain relief up to 3 times - allow tablet to dissolve bc it is absorbed sublingually - check expiration date (replace 3-5 months) - if no relief after one dose, call 911 or call rapid response team

Question 63

Action of ASA for Angina and MI

Answer 63

Reduces inflammation, pain, and decreases platelet aggregation

Question 64

ECG Patient Education

Answer 64

Remain still and breathe normally

Question 65

MI Lab Monitoring

Answer 65

Troponin T and I rise quickly, indication of MI and cardiac necrosis

Question 66

Chest Pain Priority Interventions

Answer 66

- Assess ABCs, defibrillate as needed - Provide continuous ECG monitoring - Obtain pt vitals - Assess/provide vascular access - Consult chest pain protocol or notify HCP or rapid response team for specific interventions - Obtain 12-lead ECG within 10 mins of report of chest pain - Provide pain relief medication and aspirin non-EC as prescribed (MONA) - Administer supplemental oxygen therapy to maintain an oxygen saturation greater than 90% - Remain calm, stay with pt if possible - Assess the pt's vitals and intensity of pain 5 mins after admin of meds - Remedicate with prescribed drugs (if vitals remain stable), and check pt every 5 mins - Notify HCP if vital deteriorate

Question 67

CAD Modifiable Risk Factors

Answer 67

- Smoking/Tobacco Use: quit smoking - Diet: avoid trans fatty acids, limit cholesterol and sodium intake - Cholesterol: check lipid levels regularly, follow health care provider’s advice for elevated cholesterol and LDL-C levels - Physical Activity: do moderate exercise 3x to 4x a week or walk daily for 30 minutes a day at a comfortable pace - Diabetes Mellitus: manage diabetes with a health care provider - Hypertension: Have BP checked regularly, seek health care provider’s advice is BP is elevated - Obesity: Avoid restrictive and fad diets, Restrict intake of saturated fats, sweetened beverages, and cholesterol-rich foods, Increase physical activity

Question 68

Complementary and Integrative Health considerations for CAD and MI

Answer 68

- Muscle relaxation, guided imagery, music therapy, pet therapy and therapeutic touch= may reduce anxiety and depression and increase adherence to activity and exercise regimens after heart surgery - Adding Omega-3-fatty acids from fish and plant sources can reduce lipid levels, stabilize atherosclerotic plaques and reducing sudden death from MI (fish 2x/week or fish supplement/day) - Resume sexual intercourse on the advice of HCP, usually after exercise tolerance test (in general-if you can walk 1 block or 2 flights of stairs without symptoms, can usually safely resume sexual activity), suggest pt initially after intercourse after a period of rest - Assess pt with diabetes mellitus for ability to control hyperglycemia - Those who experience MI may need dual anti platelet therapy

Question 69

Insulin Glargine (Lantus) Patient Education

Answer 69

Advise patient to never share insulin pens due to risk for transmission of bloodborne pathogens Side effects may include injection site reactions, lipodystrophy, pruritus, rash, edema, or weight gain Advise patient to monitor for signs of hypoglycemia or hyperglycemia and to report difficulties in glycemic control Counsel patient to administer at the same time each day Instruct patient to carefully check the insulin label before each use to avoid medication errors Advise patient to never mix or dilute with any other insulin or solution Teach patient proper technique and placement of injections

Question 70

Preventing Complications from Diabetes Mellitus

Answer 70

- Preventing injury from hyperglycemia, control BG and monitor for s/s of hyper/hypoglycemia - Control risk factors such as obesity, HTN, tobacco use, BP Control, smoking cessation, lipid-lowering medications and ASA - Yearly Eye Exam, report vision changes - Preventing injury from peripheral neuropathy: Annual podiatrist apt, daily foot inspection/care, report numbness/tingling, always wear proper shoes - Reducing the risk for kidney disease: Monitor Kidney Function, I&O’s, Report output less than 30mL/hr, monitor BP, Diuretics Preventing complications, Consume 2-3L of fluid/day, avoid soda, alcohol, acetaminophen, NSAID’s, report decreased output - Hand hygiene, and wear gloves with pt. care; Maintain strict asepsis for dressing changes, wound care, IV therapy, and catheter handling; ensure that any articles used are properly disinfected or sterilized before use, maintain good personal hygiene, wash hands frequently, never share insulin pen, get flu vaccine, wear covered footwear, wear clean socks everyday

Question 71

Foot Care Patient Education

Answer 71

- inspect feet daily, especially ares between toes - wash feet daily with lukewarm water and soap, dry thoroughly - apply moisturizer on feet, except between toes, after bathing - change into clean cotton socks every day - do not wear the same pair of shoes 2 days in a row and only wear shoes made of breathable materials - check shoes for foreign objects, before putting them on. Check inside show for crack or tears in the lining - Buy shoes with plenty of room for toes. Buy shoes later in the day when feet are usually larger. Break in new shoes gradually - wear socks to keep feet warm - trim toenails straight across with a nail clipper and smooth them with an emery board - see diabetes HCP immediately if you have blisters, sores or infection. Protect area with dry, sterile dressing. Do not use tape to secure dressing to skin - do not treat blisters, sores, or infections with home remedies - do not smoke or use nicotine products - do not step into bath tub without checking the temperature with your wrist or thermometer - do not use very hot or cold water. Never use hot-water bottles, heating pads, or portable heaters to warn your feet - do not treat corns, blisters, bunions, calluses, or ingrown toenails yourself - do not go barefoot - do not wear sandals with open toes or straps between toes - do not cross your legs or wear garters or tight stocking that contract blood flow - do not soak your feet

Question 72

Hypoglycemia Treatment

Answer 72

Unconscious: - Place in lateral position – prevents aspiration - Administer: Glucagon SQ/IM, D50 or IV Dextrose Conscious: - Provide readily absorbable carb: 4-6oz fruit juice or regular soft drink, Glucose tablets/gel, Hard candies - Recheck BG 15 Min After Intervention

Question 73

Lispro Insulin Administration

Answer 73

- Give within 10 minutes of mealtime - Verify correct med and strength - Do not share insulin pens or cartridges among patients - 4-, 5-, or 6-mm needles recommended in all patients regardless of BMI or age; inject at a 90-degree angle except when injecting into limbs, a slim abdomen, or in thinner children; for these situations, use a lifted skin fold (4- and 5-mm needles) or a 45-degree angle (6-mm needle)) - Use caution in patients with visual impairment who may rely on audible clicks to dial their insulin dose - Monitor for signs of hypoglycemia - if BG is low, wait to administer until sometime after meal

Question 74

S/S of Hypoglycemia

Answer 74

cool, clammy, "sweaty", anxious, nervous, irritable, mental confusion, seizures, coma, weakness, double vision, hunger, tachycardia, and palpitations

Question 75

S/S of Hyperglycemia

Answer 75

Warm, dry, vasodilator, dehydrated, rapid deep kussmaul type, acetone odor (rotten fruit) to breath Mental status varies from alert to stuporous to obtunded or frank coma Acidosis: hypercapnia, abd cramping, N/V Dehydration: decreased neck vein filling, orthostatic hypo, tachycardia, poor skin turgor

Question 76

Diet Teaching for Pt with DM

Answer 76

- Patient should work with Registered Dietitian/Nutritionist - Be Consistent - Carbohydrates: Limit Simple Sugars, Stick to Complex Carbs - Low Fat/Sodium - Many people with DM follow carb counting diets