Exam 2 Flashcards
1
Q
What are the three changes in aging that cause dimished gas exchange in older adults?
A
1) Diminished respiratory muscle strength
2) Weaker cough = aspiration risk
3) Alveoli have low elasticity causing frequent dyspnea
2
Q
What are three ways impaired ventilation occurs?
A
1) Inadequate respiratory muscle, bone, or nerve function
2) Narrorwed or obstrcuted airways from bronchoconstirction or object
3) Poor gas exchange at alveoli
3
Q
At what point during respiration do you hear crackles while ascultating the lung and what may it indicate?
A
1) Hear them during inhalation sounding like a crackling or bubbling
2) Air is moving through liquid = edema or pneumonia
4
Q
At what point during respiration do you hear wheezing while ascultating the lung and what may it indicate?
A
1) Hear it during inhale and/or exhale; sounds musical, high pitched
2) Air is moving through a narrowed airway = asthma, COPD
5
Q
At what point during respiration do you hear rhonchi and what may it mean?
A
1) You hear it during inhale and/or exhale; low pitched snoring sounds
2) Air is moving through/by thick mucus = COPD, pneumonia
6
Q
What is normal SaO2?
1) 94%+
2) 93%+
3) 95%+
A
3) 95%+
7
Q
What is the normal range for PaO2?
1) 70-100 mmHg
2) 80-100 mmHg
3) 90-100 mmHg
A
2) 80-100 mmHg
8
Q
What are primary prevention methods to improve gas exchange?
A
1) Infection control
2) Smoking cessation
3) Immunization
9
Q
What are ways to prevent post-op gas exchange problems?
A
1) Incentive spirometry Q1H while awake
2) Coughing and deep breathing Q1H (splinting)
3) DVT prevention for PE -> sequential compression, early ambulation, anticoagulants
10
Q
How often should incentive spirometry be preformed?
1) Q1H
2) Q2H
3) Q4H
A
1) Q1H while awake
11
Q
In order to maintain proper ventilation, is it better to eat smaller, more frequent meals high in calories and protein, or is it better to eat larger, less frequent meals high in proteins and calories
A
It is better to eat smaller, more frequent meals higher in calories and proteins
12
Q
Bronchodilators should be used:
1) Before meals
2) After meals
3) Partway through meals
A
1) Before meals to open airways to maintain proper ventilation while eating
13
Q
When eating patients should be placed:
1) In semi-fowlers or tripod
2) In high-fowlers or tripod
3) In trundelenberg or tripod
A
2) In high fowler’s or tripod to promote airway patency and ventilation
14
Q
What should be done before meals to improve the taste of food:
1) Administer bronchodilators
2) Place in high-fowler’s
3) Provide oral care
A
3) Provide oral care as it removes plaque, build up, and moistens the tongue
- The other two should be done before meals, but do not improve the taste of food
15
Q
True or false: COPD is a collection of lower airway disorders with airflow and gas exchange including emphysema and asthma
A
False: COPD does include emphysema and chronic bronchitis, not asthma
16
Q
Describe emphysema:
A
It is a destructive problems of lung elastic tissue of alveoli that reduces its ability to recoil after stretching leading to hyperinflation
17
Q
What is primary emphysema?
A
It is a decrease in enzyme alpha 1 antitrypsin, which normally protects against protease enzymes, found in non-smokers as an inherited disorder
- Lack of AAT allows proteases to harm elastic tissue of the alveoli
18
Q
What is secondary emphysema?
A
It is when cigarette smoking, air pollution, occupational exposure, or another respiratory tract infection in childhood triggers an inflammatory reaction promoting proteases to break down the elastin in alveoli
19
Q
What are proteases? How does cigarette smoke cause issues related to proteases?
A
1) enzymes that eliminate particulates during breathing
2) Cigarette smoke triggers high levels of proteases that damage the alveoli breaking down the elastin = less recoil causing collapsing and narrowing of the lungs reducing area for gas exchange
20
Q
What does emphysema do to the diaphragm?
1) Hyperinflated lungs flatten the diaphragm, weakening it
2) Hyperinflated lungs cause diaphragm contraction, strengthening it
3) Hyperinflated lungs do not put pressure on the diaphragm, they only put pressure on the chest wall leaving breathing unchanged
A
1) Hyperinflated lungs flatten the diaphragm, weakening it
21
Q
What does flattening of the diaphragm cause?
1) Nostril flaring, coordinated breathing, and relaxed respiratory muscle tone
2) Uncoordinated breathing and relaxed respiratory muscle tone
3) Use of accessory muscles, air hunger sensation, uncoordinated breathing
A
3) Use of accessory muscles, air hunger sensation, uncoordinated breathing because inhalation starts before exhalation is complete
22
Q
How does decreased gas exchange surface affect acid base balance and SpO2?
1) Causes respiratory alkalosis and low SpO2
2) Causes respiratory acidosis and low SpO2
3) No changes in acid base balance but increases SpO2
4) Respiratory acidosis and high SpO2
A
2) Respiratory acidosis and low SpO2
23
Q
What three signs characterize chronic bronchitis?
1) Increased mucus production, chronic cough, inflammation of bronchioles
2) Decreased mucus production, acute cough, inflammation of bronchioles
3) Increased mucus production, chronic cough, inflammation of alveoli
A
1) Increased mucus production, chronic cough, inflammation of bronchioles
24
Q
What causes chronic bronchitis?
A
Cigarette smoke is the main cause and other inhaled irritants can cause it leading to increased proteases, elastin breakdown = air trapping and reduced gas exchanged, cilia are also impaired harming cilial removal of mucus and fluid
25
How is air trapped in chronic bronchitis?
Thick mucus and narrowed airways due to inflammation trap air
26
What causes infection risk in chronic bronchitis?
1) Increased cough resulting in the patient placing their hands near their mouth frequently
2) Air trapping reducing fresh air in the alveoli allowing bacteria to proliferate
3) Increased mucus production allowing bacteria to proliferate
3) Increased mucus production allowing bacteria to proliferate
27
Describe cor pulmonale and how it developes in COPD
It is right-sided heart failure caused by chronic bronchitis and/or emphysema.
Decreased blood flow d/t air trapping and stiff alveoli walls -> increases pressure -> narrowing long blood vessels -> increased heart workload against pressure -> right heart enlarges and thickens -> right-sided HF develops with venous backup
28
What are ways to prevent COPD?
**1)** Quit smoking and vaping
**2)** Avoid particulate matter (work exposure, hobby exposure, wear proper PPE)
29
What are the 3 most accurate risk factors for COPD?
1) Male, under 65 years old, history of particulate exposure
2) Female, 65 years and older, history of cigarette smoking
3) Female, 65 years and older, chronic sputum production
2) Female, 65 years and older, history of cigarette smoking
- not males, 65 years and older, sputum production is not a risk factor it is a symptom
30
List some signs and symptoms of COPD:
- thin, loss of muscle mass in extremities
- enlarged neck
- slow moving
- orthopnea (difficulty breathing while lying down)
- accessory muscle use
- RR 40-50 (emergency)
- Sits forward in tripod position
- Barrel chest (anterior and posterior chest are same size)
- Delayed capillary refill
- Finger clubbing
- Dependent edema
31
What does an ABG look like in COPD?
1) Respiratory acidosis and metabolic acidosis
2) Respiratory alkalosis and metabolic acidosis
3) Respiratory acidosis and metabolic alkalosis
4) Respiratory alkalosis and metabolic alkalosis
**3)** Respiratory acidosis (you have poor O2 exchange and hypercapnia) and metabolic alkalosis because the body is chronically absorbing bicarbonate to compensate
32
What is the primary lab in diagnosing COPD?
ABGs
33
Which lung volume is most affected in COPD?
1) Residual volume
2) Inspiratory reserve volume
3) Expiratory reserve volume
4) Tidal volume
**1)** Residual volume b/c of air trapping, more air is left over increasing residual volume significantly
34
What is the main priority in COPD and what are three other priorities?
**1) Maintaining airway and gas exchange**
**2)** Weight loss d/t dyspnea (a lot of metabolic work to breathe hard)
**3)** Fatigue d/t low O2 but high demand
**4)** Infection risk - pneumonia
35
How do SABA (short acting beta agonists) work? What education should you provide to the patient with COPD?
**1)** They induce bronchodilator by relaxing smooth muscle via activation of pulmonary beta-2 receptors
**Education:**
- Carry your inhaler at all times for life-saving moments
- Know that it may cause your heart rate to go up along with systemic symptoms because it is non-specific
- Take your SABA inhaler 5 minutes before other inhaled agents to improve their effects
36
Albuterol can be used for acute COPD exacerbations. What medication can also be used for COPD exacerbations?
1) Tiotropium
2) Salmeterol
3) Fluticasone
4) Ipratropium
**4)** Ipratropium
- Tiotropium is the same medication class as ipratropium, cholinergic agonists, but tiotropium is a long-acting agent while ipratropium is a short-acting agent helpful for COPD exacerbations
37
How do long-acting beta agonists assist in COPD? Can they be used for acute COPD relief? What are some of these medications?
- LABAs relax bronchial smooth muscle by activating pulmonary beta-2 receptors.
- No, they cannot be used for acute COPD exacerbation, they have a slow onset
**Medications:**
- Salmeterol, indacterol, formoterol "-erols"
38
How do cholingeric antagonists (Anticholinergics) assist in COPD? What are some education points? What are some of these medications?
- They cause bronchodilation by inhibiting PSNS allowing SNS to dominate releasing epinephrine for pulmonary beta-2 receptor activation
- They prevent bronchospasm and improve gas exhcange
**Education:**
- If a reliever (ipratropium), carry at all times
- Shake inhaler well if it is a metered dose inhaler
- Increase daily fluid intake d/t mouth dryness
- Report blurred vision, headache, eye pain, nasuea, tremors, dryness as they are signs of an overdose
**Medications:** aclidinium, ipratropium, tiotropium, umeclindium, "-iums"
39
How do corticosteroids help in COPD? What are important education points? What are some corticosteroid medications?
- They help in COPD by disrupting inflammatory pathways reducing mucus production and relieving narrowed airways
**Education:**
- Use them daily even with no symptoms present because maximum effectiveness comes with 48-72 hour use
- Perform good oral care because there is an increased risk of infection such as Candida
- Rinse mouth after use to prevent Candida infection
- It is not for symptomatic use
**Medications:** fluticasone, beclomethasone, budesonide
40
How do mucolytics work in COPD? What kind of toxicity can occur? What is one medication?
- They work by thinning secretions
**Education:**
- Hepatotoxicity is possible
**Medication:**
- Acetylcystine
41
How often should patients with COPD be monitored?
1) Q4H
2) Q6H
3) Q1H
4) Q2H
**4)** Q2H
42
What are two breathing techniques to use for patients with COPD?
1) Diaphragmatic breathing and nostril flaring
2) Pursed lip breathing and tripod position
3) Pursed lip breathing and diaphragmatic breathing
4) Tripod position and high fowlers
**3)** Pursed lip breathing and diaphragmatic breathing
- Tripod, high fowlers, and nostril flaring can help with oxygenation but are not breathing techniques
43
What oxygen saturation should patients with COPD be kept at?
1) 94-99%
2) 90-95%
3) 82-91%
4) 88-92%
**4)** 88-92%
- Placing them on oxygen at a rate higher to bring them up can knock out their drive to breathe. Their breathing drive becomes more about SpO2 levels than SpCO2 levels because of chronically lowered O2 and chronically high CO2. Thus, when they are over oxygenated, their body believes it does not need to breathe.
44
How much fluid should a nurse encourage a patient with thick mucus secretions due to chronic bronchitis consume?
1) 2L/day
2) 3L/day
3) 4L/day
4) 1L/day
**1)** 2L/day to thin mucus
45
What are s/s of COPD exacerbation?
**1)** RR 40-50
**2)** O2 below 80-85%
**3)** Cyanosis
**4)** Altered mental status/confusion
**5)** Accessory muscle use
**6)** Wheezing/crackles
46
What are signs and symptoms of early hypoxia (select all that apply):
1) Bradypnea
2) Cyanosis
3) Tachycardia
4) Pale Skin (pallor)
5) Barrel Chest
6) Confusion/irritability/restless
**3)** Tachycardia
**4)** Pale Skin
**6)** Confusio/irritability/restless
1 and 2 are signs of late hypoxia and 5 is a sign of chronic hypoxia
47
Name early signs of hypoxia:
**1)** Confusion, irritability, restless
**2)** Tachypnea (>20)
**3)** Tachycardia
**4)** Elevated BP
**5)** Pale skin
**6)** Intercostal retractions
**7)** O2 <90%
48
Name signs of late hypoxia:
**1)** Stupor
**2)** Cyanosis
**3)** Bradypnea (< 12RR)
**4)** Bradycardia
**5)** Hypotension
**6)** Cardiac dysrhythmias
49
Name signs of chronic hypoxia:
**1)** Nail clubbing
**2)** Barrel chest
**3)** Cyanosis
**4)** Delayed capillary refill
**5)** Pursed lip breathing
50
How can weight loss be prevented in COPD?
**1)** Eat high calorie, high protein meals
**2)** Eat small frequent meals
**3)** Non-gas producing foods
**4)** Bronchodilator 30-min before eating to reduce difficulty eating
51
How would we know weight loss prevention in COPD is successful? If weight is kept within ______ % of ideal body weight:
1) 15%
2) 10%
3) 5%
4) 3%
**2)** 10%
- weight should be kept within 10% of ideal body weight
52
What is a core issue in using inhaled anticholinergics (cholinergic antagonists)?
1) Dry mouth
2) Increased saliva production
3) Unproductive cough
4) Swelling of the tongue
**1)** Dry mouth
- Anticholinergics are very drying = dry mouth, reduced saliva production, dry eyes, constipation
53
What should one take to help manage a COPD exacerbation?
1) Salmetrol and then fluticasone
2) Aceylcystine and then tiotropium
3) Albuterol or ipratropium and then salmeterol
4) Albuterol or ipratropium and then fluticasone
**4)** Albuterol or ipratropium and then fluticasone
- Albuteral and ipratropium are both relieving inhalers and the inhaled coriticosteroid should be continued
54
True or false, you should hold your breath for 10 seconds after taking a puff of your inhaler
**True**, after inhaling slowly for 3-5 seconds, hold your breath for 10 seconds and then exhale
55
How long should you wait between doses of the same inhaler and doses of a different inhaled medication?
1) 1 minute for same inhaler and 5 minutes between different inhalers
2) 5 minutes for the same inhaler and 1 minute between different inhalers
3) 1 minute for the same inhaler and 1 minute between different inhalers
4) 2 minutes for the same inhaler and 5 minutes between different inhalers
**1)** 1 minute for same inhaler and 5 minutes between different inhalers
56
Pneumonia: What is it, what are signs and symptoms, and what are some diagnostics?
**What is it:** it is a lung infection due to bacteria, viruses, or fungi causing inflammation and fluid build up in the airways
**S/S:** fever, chills, malaise, loss of appetite, myalgia, cough (productive or not), dyspnea, increased RR, labored breathing, crackles, rhonchi, low O2 saturation
**Dx:** increased WBC, sputum culture, chest x-ray, blood culture, ABG
57
What is the priority in pneumonia and what are possible interventions?
**Priority:** impaired gas exhcange = improve
**Interventions:** Increase HOB, early mobilization, O2 support, incentive spirometry, cough + deep breathing, bronchodilators
58
What two medications can treat pneumonia?
1) Penecillin and Ceftriaxone
2) Levofloxacin and albuterol
3) Ceftriaxone and Levofloxacin
4) Metoprolol and Diltiazem
3) Ceftriaxone and Levofloxacin are two different broad spectrum antibiotic classes that can treat bacterial pneumonia infections
59
Ceftriaxone and Levofloxacin: what class of antibiotic do they belong to, what side effects do they have, what teaching should you provide to patients
**1)** Ceftriaxone
**- Class:** Cephalsoporin
**- Side effects:** very safe overall, allergic reactions are main concern d/t cross-sensitivity to penicillin
**- Teaching:** complete entire course
**2)** Levofloxacin
**- Class:** Fluroquinolone
**- Side effects:** nausea, vomiting, swelling/rupture of tendon, c. diff and yeast infections
**- Teaching:** take with food, avoid sun exposure, complete entire course
60
What are the goals and outcomes for O2, infection, and anxiety in pneumonia?
**1)** O2 will be maintained at 92%
**2)** Free of infection with no fever and normal WBC
**3)** Anxiety is at baseline
61
What are risk factors for peripheral artery disease?
**1)** Sedentary lifestyle
**2)** Smoking
**3)** Stress
**4)** Older adult
**5)** High fat diet
**6)** Diabetes
62
What is intermittent claudication and what disease is it associated with?
**Intermittent claudication:** is the classic leg pain characterized by burning and cramping with movement stoppoing upon rest
Associated with peripheral artery disease (PAD)
63
How can peripheral artery disease become dangerous?
1) It causes microbleeds in the vasculature of lower extremities
2) It causes extreme edema at later stages, decreasing perfusion
3) It can lead to ulcers that immediately lead to amputation
4) It can cause blockages in the lower extremities, leading to necrosis and gangrene
**4)** It can cause blockages or full occlusions decreasing blood flow which causes cell death, gangrene, and necrosis
64
What are symptoms of periperal artery disease? (select all that apply)
1) Hair loss
2) Dusky/pale/ashy skin
3) Puritis
4) Cold extremities
5) Petechiae
6) Muscle atrophy
**1)** hair loss
**2)** Dusky/pale/ashy skin
**4)** Cold extremities
**6)** Muscle atrophy
- Puritis (itching) and petechiae (or small purple bruising) are not characteristic of PAD
65
What diagnostic tests can be conducted to diagnose peripheral artery disease (PAD)? (select all that apply)
1) Magnetic Resonance Angiography
2) Echocardiogram
3) Ankle-brachial index
4) Venous duplex ultrasound
**1)** Magnetic resonance angiography helps to assess blood flow in arteries
**3)** Ankle-brachial index - assesses brachial and ankle BP and divides ankle/brachial
66
What ankle-brachial index (ABI) is indicative of peripheral artery disease?
1) < .90
2) < .70
3) .90-1.0
4) < .80
**1)** <.90
- ankle BP will be lower than brachial d/t occlusion
67
What is the primary cause of peripheral artery disease?
**1)** Atherosclerosis
68
How is exercise beneficial in peripheral artery disease?
1) Decreases CO2 in circulation
2) Increases collateral circulation
3) Increases hair growth
4) Promotes venous stasis
**2)** Increase collateral circulation improving blood flow
69
True or false: Individuals with PAD should avoid wearing constrictive clothing and crossing their legs
**True:** both can reduce blood flow to the legs and feet
70
How can vasodilation be promoted in peripheral artery disease:
**1)** Keep yourself warm (warm house, wear socks, wear insulated shoes) - do not put warm items on skin d/t reduced sensation
**2)** Prevent cold exposure b/c it causes vasoconstriction
**3)** Complete abstinence from smoking and tabacco b/c it causes vasoconstriction
**4)** Avoid caffeine d/t vasoconstriction
71
What two antiplatelet medications can be used for periperal artery disease?
1) Warfarin & Heparin
2) Lovenox & Aspirin
3) Aspirin & Clopidogrel
4) Clopidogrel & Apixaban
**3)** Aspirin and Clopidogrel can be used independently or dually for antiplatelet therapy
72
What should not be use with clopidogrel?
Grapefuit juice as it can reduce its effects
73
Which medication can help with intermittent claudication in peripheral artery disease?
1) Aspirin - Antiplatelet
2) Lisinopril - ACE inhibitor
3) Heparin - Anticoagulant
4) Cilostazol - Phosphodiesterase inhibitor
**4)** Cilostazol - Phosphodiesterase inhibitor helps with intermittent claudication, increase walking distance, and increase HDL levels
74
What is venous insufficiency?
**Prolonged venous hypertension causing stretching of the veins and damaging valves** leading to backup and stasis of blood
75
What are signs and symptoms of venous insufficiency?
**1)** Edema
**2)** Stasis ulcers that are difficult to heal
**3)** Stasis dermatitis
**4)** Skin pigmentation changes (hyperpigmentation)
**5)** Pedal pulses present
**6)** ABI is normal
76
What are two ways to increase venous return to treat venous insufficiency?
**1)** Compression stockings
- Teds (for beds) for bedridden patients
- Jobst (medical compression = need prescription) for ambulatory patients
**2)** Elevate legs above heart for >30 minutes/day 3-4x
77
What is the difference between ulcers in PAD and venous insufficiency?
**PAD Ulcers**
- Usually on toes, on top of or in between or lateral malleolus (ankle)
- Well-defined edges
- No bleeding
- Deep
**Venous Ulcers:**
- Usually on medial malleolus (inside ankle)
- Uneven ulcer edges
- Granulation tissue
- Superficial
- Hard to heal
78
What kind of dressings can be used to treat venous ulcers?
**1)** Hydrocolloid dressings placed with aspetic technique
**2)** Gauze dressing moistened with zinc oxide (unna boot)
79
What are the thee parts to Virchow's Triad that contribute to DVT/VTE?
**1)** Reduced arterial flow/venous stasis (a-fib, immobility, venous insufficiency, prolonged sitting)
**2)** Endothelial injury (smoking, trauma, hypertension, surgery)
**3)** Hypercoagulability (sepsis, smoking, COVID-19)
80
What are symptoms of deep vein thrombosis (DVT/VTE)?
**1)** Calf/groin pain
**2)** Sudden onset of unilateral leg swelling
**3)** Induration (hardening of skin)
**4)** Warmth/redness
**5)** Edema
81
What is the diagnositc standard for deep vein thrombosis (DVT)?
Venous duplex ultrasonography to assess flow
82
What is the priority in DVT?
Prevent complications of DVT (embolus -> PE, or increase in size) and anticoagulation
83
What are interventions in DVT aside from anticoagulant therapy?
**1)** Gradual ambulation
**2)** Bed rest and leg elevation
**3)** Compression stockings
**4)** warm, moist soaks
84
How long does it take before the therapeutic effect of warfarin is seen? Why is this important if transitioning from unfractionated heparin?
It takes 3-4 days before seeing therapeutic effect, thus warfarin and heparin must be used at the same time; heparin acts as a bridge for warfarin to start working
85
What is the reversal agent for unfractionated heparin?
1) Andexanet alfa
2) Vitamin K
3) Idarocizumab
4) Protamine sulfate
**4)** Protamine sulfate
86
What is the reversal agent for warfarin?
1) Protamine sulfate
2) Vitamin K
3) Andexanet alfa
4) Idarocizumab
**2)** Vitamin K
87
What is the reversal agent for dabigatran?
1) Protamine sulfate
2) Vitamin K
3) Andexanet alfa
4) Idarocizumab
**4)** Idarocizumab
88
What is the reversal agents for edoxaban, apixaban, and rivaroxaban?
1) Andexanet alfa
2) Vitamin K
3) Idarocizumab
4) Protamine sulfate
**1)** Andexanet alfa
89
Why should reversal agents for anticoagulants only be used as a last resort?
They cause an extreme risk for clotting
90
Which labs are primarily monitored in warfarin therapy?
1) aPTT and INR
2) INR and PT
3) PT and aPTT
4) Antifactor Xa and XIa
**2)** INR and PT
91
When would one consider administering protamine sulfate to reverse heparin treatment?
1) If the therapeutic range of PTT is >90 seconds
2) If the therapeutic range of aPTT is >50 seconds
3) If the therapetuic range of aPTT is >100 seconds
4) If the therapeutic range of PTT is < 175 seconds
**3)** If the therapeutic range of aPTT >100 seconds
- This indicates the blood is taking too long to clot and they are at high risk of bleeding
92
Which labs are primarily monitored in heparin therapy?
1) aPTT and INR
2) INR and PT
3) PT and aPTT
4) PTT and aPTT
**4)** PTT and aPTT
93
How often should PT and INR be drawn for warfarin therapy at the start of therapy?
1) Q24H (1x/day)
2) Q6H (4x/day)
3) Q12H (2x/daily)
4) Q3H (8x/day)
**1)** Q24H (1x/day) to monitor therapeutic range
94
How often should aPTT be drawn for warfarin therapy?
6 hours after the initial dose and then after every dose given
95
What is the therapetuic range for INR for DVT treatment?
1) 3-4
2) 1.5-2
3) 2-3
4) 1-2
**3)** 2-3 for treatment of DVT
- 1.5-2 is for DVT prophylaxis
96
What are two benefits of taking direct oral anticoagulants (apixaban, rivaroxaban, endoxaban) aside from their direct action of thinning the blood?
**1)** There are fewer drug interactions
**2)** There is less frequent lab monitoring
97
What are the signs/symptoms of bleeding to monitor for while a patient is on anticoagulant therapy?
**1)** Sudden bleeding of the gums or nose
**2)** Petechiae or ecchymosis (bruising)
**3)** Hematuria (blood in the urine)
**4)** Abdominal pain
**5)** Altered mental status
**6)** Tachycardia
**7)** Hypotension
**8)** Tachypnea
98
What should be taught to a patient starting on anticoagulants?
**1)** S/S of bleeding and report any bleeding
**2)** Do not use a straight razor, use an electric razor
**3)** Do not abruptly stop medications
**4)** Take at the same time each day
99
What kinds of emboli can cause pulmonary embolsim?
**1)** Air
**2)** Fat
**3)** Amniotic
**4)** Cancer
**5)** DVT clot (most common)
100
List the four concerns in order of priority in pulmonary embolsim?
- Anxiety
- Hypotension
- Hypoxemia
- Bleeding
**1)** Hypoxemia (V/Q) mismatch
**2)** Hypotension (left ventricle left with inadequate flow)
**3)** Bleeding (due to anticoagulant therapy)
**4)** Anxiety (related to hypoxemia and threat to life)
101
What are some signs and symptoms of impaired gas exhange during pulmonary embolism?
**1)** Sudden dyspnea
**2)** Tachypnea
**3)** Sharp, stabbing chest pain
**4)** Feeling of impending doom
**5)** Lightheaded
**6)** Diaphoresis
**7)** Cough
**8)** Hemoptysis (bloody sputum)
102
What are some signs and symptoms of impaired perfusion during pulmonary embolism?
**1)** Tachycardia
**2)** Distended neck veins
**3)** Crackles in lungs d/t edema
**4)** Hypoxia
**5)** Cyanosis
**6)** Pulmonary hypertension
**7)** Systemic hypotension
103
What is the diagnostic imaging standard for pulmonary embolism?
CTPA: Computed Tomography Pulmonary Angiography
104
What labs can you examine to help determine pulmonary embolism?
**1)** D-dimer (clot breakdown) >250 ng/mL
**2)** ABG (metbolic acidosis d/t lactic acid build up)
**3)** Troponin (elevated)
**4)** BNP (elevated)
105
What nursing interventions should be taken during pulmonary embolism to address hypoxemia?
**1)** Call rapid response team
**2)** Administer supplemental O2 if below 90%
**3)** Place in semi-fowler's position
**4)** Obtain IV access
**5)** Heparin bolus or use LMWH if HIT is a concern
**6)** Alteplase if severe
**7)** Assess cardiac and respiratory systems
**8)** ABGs
**9)** Vitals
106
When should alteplase be used during pulmonary embolism?
Only if the patient is becoming unstable such as going into shock
107
What nursing interventions should be taken during pulmonary embolism to address hypotension?
**1)** Administer IV crystalloid fluids to restore plasma volume and prevent shock
**2)** Monitor urine output
**3)** Monitor mucus membranes and skin turgor
**4)** Monitor s/s of heart failure
**5)** Vasopressors if fluids are failing
108
What nursing interventions should be taken during pulmonary embolism to address bleeding?
**1)** Have reversal agents ready (Warfarin = vitamin K, heparin = protamine sulfate)
**2)** Monitor for s/s of bleeding (hypotension, increased HR, abdominal distension/pain, sudden bleeding or bruising without cause, hematura, hemoccult stool)
**3)** CBC/PLT labs
109
What is a closed pnueomothorax?
When the pleural cavity has less pressure than atmospheric causing air to leak into the chest from the lungs
110
What is an open pneumothorax?
When the pleural cavity has equal pressure to atmohspheric caused by a hole in the chest wall leaving the lungs open to the outside
111
What is a tension pneumothorax and why is it life-threatening
A tension penumothorax is a type of closed pneumo when the pleural cavity pressure is greater than atmospheric.
It is dangerous because air continues to build up in the chest cavity, but cannot exit because the punctured lung acts as a 1-way valve allowing air into the chest, but covers the hole during expiration so it cannot leave. The build up of air can place pressure on the heart and trachea deviating them.
112
What are causes of pneumothorax?
**1)** Medical procedures
**2)** Underlying conditions like COPD
**3)** Chest trauma
113
What are signs and symptoms of pneumothorax?
**1)** Respiratory discomfort
**2)** Chest pain
**3)** Shortness of breath
**4)** Tachypnea
**5)** Assymetric lung expansion
**6)** Decreased or absent lung sounds on affected side
**7)** Tachycardia
**8)** Hypotension
**9)** Tracheal deviation
**10)** Jugular vein distension
**11)** Cyanosis
114
What is the main diagnostic imaging for pneumothorax?
Chest x-ray
115
Where is the air drain and fluid drain placed in patients with a chest tube?
Air drain is placed high on the lung apex
Fluid drain is placed low near the lung base
116
Why is it important that fluid be drained from the drainage system or that a new system be connected if one is filled during chest tube drainage?
Because if fluid backs up from the system into the tube drainage can stop and cause another penumothorax or effusion
117
How often should the nurse monitor the drainage system after chest tube placement within the first 24 hours?
1) Q1H
2) Q2H
3) Q4H
4) Q6H
**1)** Q1H
118
How many centimeters (cm) of water should be placed in the water seal chamber of the chest tube drainage system?
1) 4cm
2) 1cm
3) 2cm
4) no water is needed
**3)** 2cm so air does not go back into the patient
119
What might a mild/moderate amount or excessive amount of bubbling in the water seal chamber indicate?
Mild-moderate bubbling indicates that air is passing through the chamber which is normal
Excessive bubbling indicates a leak is present
120
What is tidaling in relation to the chest tube system? What might an absence of tidaling indicate?
**Tidaling:** the normal rise of water-seal chamber liquid by 2-4cm during inhalation and fall during exhalation
**Absence of tidaling** can indicate that the lung is healed or there is an obstruction in the tube
121
What should be kept next to the bedside of a chest tube system?
**1)** Padded clamps
**2)** Sterile gauze
122
What is sinus tachycardia?
SA node discharge rate of >100 BPM
123
What are possible causes of sinus tachycardia?
**1)** Fever/infection
**2)** Pain
**3)** Anxiety/Fear
**4)** Caffeine
**5)** Hypovolemia
124
What are some signs and symptoms of sinus tachycardia?
**1)** Palpitations
**2)** Chest pain
**3)** Dizziness
**4)** SoB
125
How is perfusion affected with prolonged sinus tachycardia?
Prolonged tachycardia decreases coronary perfusion time, decreases diastolic filling, and reduced coronary perfusion pressure = low O2 ouput with high O2 demand
126
How do you treat sinus tachycardia?
**1)** Treat underlying cause
**2)** Treat/mitigate fall risk
127
What is sinus bradycardia?
SA node discharges at **< 60BPM**
128
What are causes of sinus bradycardia?
**1)** Vomiting
**2)** Suctioning
**3)** Valsava maneuvers (bearing down, gagging)
129
What are signs/symptoms of sinus bradycardia?
**1)** Diaphoresis
**2)** Chest pain
**3)** SoB
**4)** Syncope
**5)** Dizziness/confusion
**6)** Hypotension
130
True or false: An individual who is stable with sinus bradycardia should receive IV atropine
**False**, individuals who are stable with sinus bradycardia should not receive treatment, only patients who are symptomatic
131
What steps do you take for symptomatic sinus bradycardia?
**1)** Administer IV atropine
**2)** Administer IV fluids
**3)** Administer supplemental oxygen to bring above 90%
132
What surgical intervention is needed in sinus bradycardia that is not responsive to medications?
A pacemaker is needed in refractory bradycardia
133
How does atropine function to improve bradycardia? What should you monitor after administering atropine?
It is an anticholingeric medication that blocks muscarinic receptors on the heart. Therefore, it inhibits the PSNS allowing the SNS to dominate **increasing HR**
**Monitor:** HR, s/s such as blurred vision, dizziness, headache, urin retention, constipation (it's very drying)
134
What is atrial fibrilation?
Atria quiver while ventricles beat at a rapid rate in response to the impulses of the atria causing a decrease in cardiac output because of poor blood filling
135
What are the signs and symptoms of atrial fibrilation?
**1)** Irregular apical pulse
**2)** fatigue
**3)** weakness
**4)** SOB
**5)** Palpitations
**6)** Chest pain
**7)** Anxiety
136
What tool is used to diagnose A-fib and what would you see?
12-lead ECG diagnosis
**1)** No clear p-wave
**2)** Irregular R-R rhythm, wont be evenly spaced
**3)** Varying HR
137
What are the 4 primary risk factors for a-fib?
**1)** Hypertension
**2)** CAD
**3)** HF
**4)** ACS
138
What is the number one priority for a-fib?
Preventing embolus formation
139
What drugs are used to treat A-fib?
**1)** Diltiazem (calcium channel blocker)
**2)** Metoprolol (beta-blockers)
**3)** Digoxin (cardiac glycoside
**4)** Warfarin
**5)** Apixaban/rivaroxaban (direct oral anticoagulants)
140
What do diltiazem, metoprolol, digoxin, and amiodarone control in A-fib?
1) Rhythm control
2) Rate Control
3) Contractility control
**2)** Rate control
141
Diltiazem: what class is it, what does it do to the heart, what should you monitor and educate on?
**What is it:** calcium channel blocker
**Heart effect:** slows SA and AV conduction slowing heart rate
**Monitor:** Hypotension, heart rate, s/s of HF
**Educate:** Slow position changes d/t orthostatic hypotension
142
Metoprolol: what class is it, what does it do to the heart, what should you monitor and educate on?
**What is it:** beta blocker
**Heart effect:** slows ventricular response by decreasing catecholamines that stimulate beta receptors
**Monitor:** heart rate and blood pressure, may cause bronchospasm
**Educate:** Slow position changes d/t orthostatic hypotension
143
Digoxin: what class is it, what does it do to the heart, what should you monitor?
**What is it:** cardiac glycoside
**Heart effect:** Increases heart **contractility,** slows AV conduction, decrease SNS activity, slows heart rate, **beneficial for HF with A. fib**
**Monitor:** Assess apical pulse for 1 minute before giving, digoxin toxicity, potassium levels becuase it can cause hyperkalemia
**Educate:** s/s of digoxin toxicity (fatigue, anorexia, blurred vision, mental status change)
144
What 2 events cause digoxin toxicity?
**1)** Hypokalemia (this triggers toxicity and taking digoxin can also cause hyperkalemia as a separate issue)
**2)** High digoxin doses
145
Warfarin: what class is it, what does it do to the heart, what should you monitor, patient education?
**What is it:** anticoagulant via vitamin K-depend clotting factor inhibition
**Heart effect:** Thins blood to prevent clotting in the heart
**Monitor:** INR, s/s of bleeding
**Educate:** Avoid ginseng, ginger, ginko, and garlic which can interfere with medication, avoid or stay consistent with vitamin K, s/s of bleeding
146
Apixaban, Rivaroxaban, Endoxaban: what class is it, what does it do to the heart, what should you monitor?
**What is it:** Direct Oral Anticoagulants
**Heart effect:** Thins blood to prevents clots in the heart
**Monitor + Educate:** s/s of bleeding
147
What 2 contributions do Warfarin and Direct Oral Anticoagulants have in A-fib?
**1)** Stroke, PE, DVT prevention
**2)** Help to convert a-fib back to sinus rhythm
148
What heart rate must you hold diltiazem, metoprolol, and digoxin?
Hold if **below 60 HR** and contact provider
149
What are the signs and symptoms of atrial fibrillation? (Select all that apply)
1) Irregular Pulse
2) Fatigue
3) Shortness of Breath
4) Bounding Pulse
5) Palpitations
6) Hypotension
7) Headache
**1)** Irregular Pulse
**2)** Fatigue
**3)** Shortness of Breath
**5)** Palpitations
**6)** Hypotension
150
What are the important priorities in treating patients with atrial fibrillation? (Select all that apply)
1) Fall prevention
2) Pain management
3) Preventing emboli formation
4) Nutritional screening
5) Antiarrhythmic medications to prevent heart failure
**3)** Preventing emboli formation
**5)** Antiarrhythmic medications to prevent heart failure
151
When educating a patient who was recently prescribed warfarin, what dietary considerations would you instruct them to implement?
1) Add foods like garlic and ginger to food to improve micronutrient intake to improve INR
2) Maintain a consistent vitamin K intake or avoid vitamin K foods
3) Increase calcium intake through supplementation and dairy products
4) Take vitamin B12 supplements to improve absorption of warfarin
**2)** Maintain a consistent vitamin K intake or avoid vitamin K foods
152
You are caring for a 68 year old male after a fall. He has a history of atrial fibrillation and is prescribed warfarin. Head CT revealed a subdural hemorrhage. What order would you anticipate receiving from the physician?
1) Administer vitamin K and prothrombin complex concentrate
2) Administer TXA
3) Administer TPA
4) Administer 1 unit of PRBCs and 1 unit of platelets
**1)** Administer vitamin K and prothrombin complex concentrate
- Both help reverse the effects of Warfarin. While TXA can help prevent excessive bleeding, it does not target warfarin's action specifically
153
What is v-tach and how many BPM?
**V-tach:** repeitive firing of the ventricles d/t irritable ventricular foci with **3 or more consecutive premature ventricular contractions**
**BPM:** 140-180
154
What ECG findings indicate V-tach?
**1)** Wide QRS
**2)** R-R interval is regular
**3)** No visible p-waves
**4)** Rapid BPM 140-180
155
What are risk factors for V-Tach?
**1)** Illicit drug use like cocaine and inhalants
**2)** Ischemic heart disease
**3)** Hyper/hypokalemia
**4)** HF
**5)** Alcohol use
156
What are signs and symptoms of V-Tach?
**1)** Dizziness
**2)** Angina
**3)** SOB
**4)** Palpitations
157
What 3 steps do you take in V-tach with a pulse?
**1)** Call for help
**2)** Attach ECG pads for 12 lead
**3)** Give amiodarone (150mg) and help with cardioversion
158
What steps do you take in pulseless V-tac?
**1)** Call 911/call for help/Rapid response
**2)** Get defebrilator or delegate someone to get it
**3)** Start CPR and continue it even while defibrilator is being set up
159
What is ventricualr fibrilation (V. fib)?
- It is when there are many irritable foci firing totaly disorganized
- No ventricular contraction
- **The ventricles quiver consuming a large amount of oxygen**
160
Why is V. fib life-threatening and how fast is it fatal?
- There is no cardiac output, no pulse, no perfusion anywhere
- It is rapdily fatal in 3-5 minutes
161
What are some causes of V. fib?
**1)** Acute MI
**2)** HF
**3)** Acidosis
**4)** hyper/hypokalemia
**5)** hypomagnesemia
162
What are signs/symptoms of V. fib?
**1)** Pulseless
**2)** Apneic
**3)** Unresponsive
**4)** Pupils dilated and fixed
163
What steps should you take during V. fib?
**1)** Call code/call 911
**2)** Start CPR
**3)** Continue CPR and defibrilate as soon as possible
164
What should you look for on an ECG to indicate V. fib?
- No recognizable deflection
- No discernable pattern, chaos
165
What is ventricular asystole?
Absence of any ventricular rhythm; no electrical impulses anywhere, no perfusion
166
What can cause ventricular asystole?
**1)** Severe hyperkalemia
**2)** Acidosis
**3)** MI
**4)** HF
167
What should you do for a patient in ventricular asystole?
**1)** Call 911/call code
**2)** Start CPR
168
What rhythms can you shock (defibrilate)? (Select all that apply)
**1)** Asystole
**2)** Atrial fibrilation
**3)** Pulseless Ventricular Tachycardia
**4)** Ventricular Tachycardia with a pulse
**5)** Ventricular fibrilation
**6)** Sinus tachycardia
**3)** Pulseless Ventricular Tachycardia
**5)** Ventricular fibrilation
169
At what depth should you perform compressions?
2-2.4 inches
170
How often do you give breaths during CPR when an advanced airway is in place?
Every 6-8 seconds
171
What is the ratio for compression to breaths in CPR? What is the rate for compressions and breaths per minute?
- 30 compression : 2 breaths
- 100-120 compressions/minutes and 10-12 breaths/minute
172
What does acute coronary syndrome encompass? (select all that apply)
1) Unstable angina
2) STEMI
3) Stable angina
4) NSTEMI
5) Ischemia
**1)** Unstable angina
**2)** STEMI
**4)** NSTEMI
173
What characterizes stable angina?
**1)** Familiar pattern
**2)** Occurs with exertion
**3)** Relieved at rest
**4)** < 15 minutes
**5)** Relieved by nitroglycerin
174
What characterizes unstable angina?
**1)** Pain intensity increases
**2)** Attacks vary
**3)** Occurs without exertion
**4)** Is **not** relieved by rest
**5)** >15 minutes
**6)** Poorly relieved by nitroglycerin
**7)** **may have ST changes**
**8)** **NO** troponin changes
175
What are the signs and symptoms of a heart attack/MI?
**1)** Chest pressure
**2)** Discomfort
**3)** SoB
**4)** Nausea
**5)** Pain/pressure/discomfort lasts longer than 30 minutes
**6)** Pain relieved only by opioids
**7)** Pain raidiates to jaw, arm, or back
**8)** Occurs **w/o cause often in the morning**
176
What signs and symptoms of a heart attack/MI are more commonly seen in biologically female individuals?
**1)** SoB
**2)** Pain between shoulder blades
**3)** Fatigue
**4)** Indigestion
177
STEMI: what ECG changes are seen, cause, treatment
**ECG:** ST elevation in 2 contiguous leads
**Cause:** rupture of atheroslcerotic plaque leading to an emboli that **occludes 100%** of the coronary vessel
**Tx:** percutaenous coronary intervention (PCI) - angioplasty w/ or w/o stent or fibrinolytic therapy if no PCI is available
178
NSTEMI: what ECG changes are seen, cause, treatment
**ECG:** ST depression and T wave inversion
**Cause:** vasospasm, dissection, or narrowing/partial occlusion of the vessel by thrombus or atheroclserosis
**Tx:** Administer 325mg of aspirin, administer clopidogrel if needed, administer beta blocker 1-2 hours after MI, ACE/ARB 24 hours after, statin for abnormal lipids
179
What is the "door-to-balloon time" in the treatment of a STEMI using percutaenous intervention?
1) < 30 minutes
2) < 60 minutes
3) < 90 minutes
4) < 20 minutes
**3)** < 90 minutes
- STEMIs can be rapidly fatal if the vessel if left occluded and must be treated within 90 minutes of arrival at the hospital
180
A patient presents to the emergency department with symptoms of a myocardial infarction. As the nurse, should you:
1) Continue taking a detailed history to obtain what occurred before they came in?
2) Administer alteplase to break up the embolus occluding the artery?
3) Delay taking a detailed history and assess the patients symptoms with yes or no questions?
4) Call a rapid and start CPR to restore coronary perfusion?
**3)** Delay taking the history and assess the patients symptoms with yes or no questions
- You should stop taking a detailed history and do a brief assessment using yes or no questions. The other options are not correct in the current scenario, you should assess your patient first
181
A patient comes into the ED with a STEMI. There is no catheterization lab available at your hospital to perform a percutaneous coronary intervention. What is the alternative treatment and how soon should it be done?
1) Administer Tranexamic acid (TXA), within 30 minutes
2) Administer tissue plasminogen activator (TPA), within 30 minutes
3) Administer unfractionated heparin, within 90 minutes
4) Administer aspirin, within 30 minutes
**2)** Administer tissue plasminogen activator (TPA) also known as Alteplase within 30 minutes of a STEMI with no PCI available
182
In what time frame should you obtain a 12-lead ECG after someone presents with chest pain?
1) < 10 minutes
2) < 30 minutes
3) < 5 minutes
4) < 90 minutes
**1)** < 10 minutes
183
After a myocardial infarction, which medication should you avoid and which is appropriate to take for pain management?
1) avoid Tylenol, take NSAIDs
2) avoid aspirin, take NSAIDs
3) avoid NSAIDs, take Tylenol
4) Avoid NSAIDs, take aspirin
**3)** Avoid NSAIDs, take tylenol
- NSAIDs can contribute to bleeding so it is best to use Tylenol for pain management following an MI
184
Which two labs indicate a myocardial infarction is likely? (select all that apply)
1) Troponin
2) INR
3) Creatinine kinase
4) Increased Ca2+
**1)** Troponin
**3)** Creatinine kinase
185
Nitroglycerin: what does it do, how many times can you give it, when should you hold it, contraindications
**What does it do:** it dilates the blood vessels allowing for blood to move past an occlusion during an MI or partial occlusion to relieve pain and restore flow
**How many times can you give:** a total of 3 times 5 minutes between each dose
HOLD IF SYSTOLIC BP IS **< 100 mmHG**
**Contraindications:** low BP, taking any erectile dysfunction medications such as **sildenafil or any other "-afils"**
186
How long is nitroglycerin good for after opening?
1) 1 year
2) 30 days
3) 1-3 months
4) 3-5 months
**4)** 3-5 months
187
How should a patient know that oral nitroglycerin is fresh and works?
If it burns when placed under the tongue
188
How should nitroglycerin be stored?
In an airtight container that blocks out sunlight
189
When should a patient outside of a hospital setting call 911 when using nitroglycerin?
They should call 911 after taking 1 pill with no chest pain relief within 5 minutes
190
When should morphine be used during myocardial infarction? What should you monitor after administering?
**Use:** used during MI if pain is not relieved by nitroglycerin
**Monitor:** BP, RR (can cause respiratory depression), HR, and vomiting
191
Why is pain management important during acute coronary syndrome?
Managing pain reduces metabolic activity reducing oxygen demand
192
When should oxygen be administered during angina/myocardial infaction?
If the patient is hypoxemia below 90% to bring their SpO2 up
193
What position should an individual be placed in during a myocardial infarction?
1) Tripod
2) High fowler's
3) Semi-fowler's
4) Supine
**3)** Semi-fowlers
- this helps with oxygenation and prevents too little blood from reaching the brain as in tripod or high fowler's
- supine does not provide comfort and oxygen support
194
A patient asks a nurse when they can resume having sex after their heart attack. The nurse should inform them that they can resume sexual activity once they can:
1) Walk 2 blocks without any symptoms
2) Run 2 miles without any symptoms
3) Climb 2 flights of stairs without any symptoms
4) Engage in any vigorous activity for 2 minutes without any symptoms
**3)** Climb 2 flights of stairs without symptoms
195
A post-MI patient is being discharged. A nurse is educating them on exercise and walking therapy. The nurse should tell the patient to stop walking when what occurs?
**1)** If they experience dyspnea
**2)** If they begin to have angina
**3)** Their target HR is exceeded, often 20BPM more than goal HR
196
What is anemia and why is it a problem?
**What:** It is an abnormally low amount of RBCs, Hgb concentration, or hematocrit
**Problem:** diminishes O2 carrying capacity to tissue and organs
197
What is the most common type of anemia?
1) Blood loss anemia
2) Iron-deficiency anemia
3) Hemolytic anemia
4) Pernicious anemia
**2)** Iron-deficiency anemia
198
What are signs and symptoms of anemia?
**1)** Fatigue
**2)** Pallor
**3)** Cold, cold sensitivity
**4)** Extertional dyspnea
**5)** Somnolence (sleepy/tired)
**6)** Numbness/tingling
**7)** Headache
**8)** Smooth, bright red tongue (pernicious anemia)
199
What vitamin can help absorb iron?
1) Vitamin C
2) Vitamin A
3) Vitamin D
4) Vitamin B12
**1)** Vitamin C
200
201
What is the normal blood pressure range?
**Systolic:** < 120 mmHG
AND
**Diastolic:** < 80 mmHg
202
What blood pressure range is the beginning of hypertension?
**Systolic:** 130-139 mmHG
OR
**Diastolic:** 80-89 mmHG
203
What are possible causes of primary hypertension?
**1)** Physical inactivity
**2)** Smoking
**3)** Obesity
**4)** Family history of hypertension
**5)** 60 years or older
**6)** Stress
204
What complications can hypertension lead to?
**1)** Stroke
**2)** MI
**3)** PVD
**4)** CKD
205
What are possible causes of seondary hypertension?
**1)** CKD (cause and complication)
**2)** Pregnancy
**3)** Oral contraceptives
**4)** Cushing's
206
What are signs and symptoms of hypertension?
**1)** Blood pressure of >130 mmHg systolic or >80 mmHg
**2)** Headaches
**3)** Dizziness
**4)** Flushing
**5)** Often asymptomatic - "silent killer"
207
How is orthostatic hypotension defined?
Loss of 20 mmHg systolic or 10 mmHg within three minutes after moving from a lying/sitting position to standing
208
How much should sodium be limited to per day in hypertension?
1) 2-3g
2) < 2g
3) < 1.5g
4) < 2.5g
**3)** < 1.5g of sodium per day
209
What are lifestyle modifications that individuals with hypertension should be encouraged to make? (Select all that apply)
1) Reduce or stop smoking
2) Increase the amount of protein they receive from deli meat and canned foods
3) Abstain or decrease alcohol consumption
4) Increase physical activity
5) Engage in intermittent fasting
6) Modify their diet to a plan like the DASH diet
7) Increase their stress levels through vigorous exercise
8) Lose weight
**1)** Reduce or stop smoking
**3)** Abstain or decrease alcohol consumption
**4)** Increase physical activity
**6)** Modify their diet to a plan like the DASH diet
**8)** Lose weight
- They should also reduce their caloric intake, and increase their calcium, potassium, fiber, and low-fat intake
210
What is the best way to improve medication adherence in hypertension?
1) Make treatment occur 1x/day
2) Provide positive reinforcement for taking medication like coupons
3) Set up a pill box for all of their medications throughout the day
4) Educate them on the side effects they may experience while taking their medication
**1)** Make treatment occur 1x/day
- It's best to make treatment 1x/day and if possible, only one type of medication to reduce the time spent thinking about their medication and negative side effects
211
What is the preferred class of pharmacological treatment in hypertension and which drug from that class is preferred?
1) Angiotensin Receptor Blockers (ARBs), Losartan
2) Angiotensin Converting Enzyme Inhibitor (ACEIs), Lisinopril
3) Diuretics, Hydrochlorothiazide
4) Calcium Channel Blocker, Diltiazem
**3)** Diuretics, Hydrochlorothiazide
- Diuretics are the drug class of choice becuase they can quickly remove excess fluid and sodium reduce blood pressure
- Hydrochlorothiazide is preferred over loop or potassium sparing becuase it is low cost, highly effective in uncomplicated hypertension, reduce calcium excretion reducing kidney stone risk, and is self-limiting thus in older adults reducing the risk of over diuresis
212
What blood pressure constitutes a hypertensive crisis?
Greater than >180 mmHg systolic AND/OR >120 mmHg diastolic
- This constitutes a medical emergency
213
What are the signs and symptoms of a hypertensive crisis aside from blood pressure?
| Think of preeclampsia/eclampsia
**1)** Severe headache
**2)** Blurred vision
**3)** Dizzy
**4)** Nose bleeding
**5)** Uremia
**6)** Anxiety
214
What 3 steps should you take when someone is in a hypertensive crisis?
**1)** Place in semi-fowlers
**2)** Administer O2 if they are becoming hypoxic to keep it above 90%
**3)** Call rapid response/911
215
Hydrochlorothiaizde: what is it, when is it used, monitoring, and education
**What is it:** a thiazide dieuretic that removes water, sodium, and potassium from the body
**Used:** #1 treatment for hypertension, and can be used in heartfailure during fluid volume overload, but loop diuretics are preferentially used
**Monitoring:**
- S/S hypokalemia (weakness, decreased reflexes, irregular pulse)
- S/S dehydration
- Glucose levels
- Renal function (BUN and Creatinine)
- Tinnitus (and other hearing problems but less common in thiazides than in loops)
- Uric acid retention - may be harmful for those with gout
**Education:**
- Eat foods high in potassium
- Rise slowly d/t orthostatic hypotension
- Take in the morning to avoid nocturia
- May affect blood glucose control
- May cause decreased libido in males
- Report tinnitus, changes in pulse, and any weakness
216
What are possible causes of heart failure?
**1)** MI
**2)** Hypertension
**3)** CAD
**4)** Valvular disease/dysfunction
217
What is systolic heart failure with reduced ejection fraction (HFrEF)?
When the heart cannot contract forcefully enough during systole to eject enough blood out, often leads to fluid back up into the atria and pulmonary system
**Ejection fraction: < 40%**
218
What is diastolic heart failure with reduced ejection fraction (HFpEF)?
When the ventricle cannot adequately relax during diastole preventing adquate blood filling for cardiac output. Ventricles become less compliant over time becuase you need more pressure to move the same amount of volume
Ejection fraction is preserved becuase while you have less filling, you still push out an adequate amount keeping the proportion similar.
**EJ: >40%**
219
What are signs and symptoms of left heart failure?
**1)** Poor activity tolerance = dyspnea and fatigue
**2)** Daytime oliguria and nighttime nocturia
**3)** Angina
**4)** Confusion, dizziness
**5)** Restless
**6)** Pallor/ashen skin
**7)** Tachycardia
**8)** Weak pulses
**9)** Cool extremities
**10)** Pulmonary congestion/edema
**11)** Orthopnea - will sleep upright and/or with a lot of pillows
220
What are signs/syptoms of pulmonary congestion/edema?
**1)** Frothy, pink-tinged sputum
**2)** Tachypnea
**3)** Hacking cough
**4)** Crackles near the base of the lungs
**5)** Restless
**6)** Pulmonary hypertension
**7)** Systemic hypotension
**8)** Oliguria
221
What three steps should be taken for someone experiencing pulmonary edema?
**1)** Place in high Fowler's position (if not hypotensive)
**2)** Provide O2 to keep at 90% SpO2
**3)** Administer IV push furosemide over 1-2 minutes to treat edema and to avoid ototoxicity
- Can also use nitroglycerin to reduce preload and afterload lessening fluid build up
222
What are signs and symptoms of right-sided heart failure?
**1)** Peripheral edema
**2)** Ascietes
**3)** Enlarged liver and spleen
**4)** Neck vein distension
**5)** Swollen hands/fingers
**6)** Polyuria at night as fluid is mobilized
**7)** Clothing and accessory do not fit well
**8)** Weight gain (10-15 lbs)
**9)** Anorexia
**10)** Nausea
223
Why is edema a poor indicator of heart failure? What is a better measure and what should you educate the patient on when they do this?
Edema is a poor measure because it take a lot of fluid retention before edema becomes apparent in heart failure
**Weight** is a better measure.
**Education:**
- Take your weight daily
- Take your weight at the same time each day
- Take your weight, preferrably in the morning before you've eaten anything
- Take your weight wearing the same clothing each time
224
How much weight gain per day and week might indicate heart failure?
2-3kg in one day
5-6kg in one week
225
What labs are elevated in heart failure? (Select all that apply)
1) BNP
2) Troponin
3) Creatinine
4) BUN
5) Hematocrit
6) GFR
**1)** BNP
**2)** Troponin
**3)** Creatinine
**4)** BUN
- Hematocrit is not elevated, it is often lowered to do fluid dilution
- GFR is typically lowered which is why we see high creatinine and BUN d/t poor kidney filtration
226
What is the diagnostic standard for heart failure?
1) Venous duplex ultrasonography
2) CTPA
3) Magnetic Resonance Angiography
4) Echocardiogram
**4)** **Echocardiogram**, can see valvular changes, pericardial effusion, chamber enlargement, vetricular hypertrophy, and most importantly, **ejection fraction**
227
What is the drug class of choice for patients with heart failure and no fluid volume overload? What about for patients with fluid volume overload?
DoC w/ no fluid volume overload are Angiotensin Converting Enzyme Inhibitors -> **ACEIs**
DoC for HF with fluid volume overload are **diuretics, mainly loop such as furosemide**
228
If ACE inhibitors do not work for a patient, what might be a second appropriate medication?
1) Lisinopril
2) Losartan
3) Hydrochlorothiazide
4) Digoxin
**2)** Losartan, we would want to switch to an ARB if ACEIs do not work for the patient
229
ACE inhibitors are very helpful drugs for patients with heart failure; however, they can cause a very annoying side effect that may prompt patients to switch to an ARB instead. What is the side effect?
1) Puritis
2) Rhinitis
3) Dry mouth
4) Cough
**4)** Cough, is a side effect of ACEIs and patients should be switched to an ARB instead
230
ACEIs/ARBs: what do they do, medications, monitoring, patient education
**What do they do:** both suppress the RAAS which helps vasodilate vessels and increase sodium and water excretion decreasing afterload and improving stroke volume
**Medications:**
- ACEIs = -"april" -> lisinopril, clanapril, captopril
- ARBs = "-artan" -> losartan, valsartan
**Monitoring:**
- Hold if patients PB < 100 mmHg systolic
- S/S of hyperkalemia
- Angioedema
- If BP drops below 90 mmHg systolic elevate legs
**Education:**
- Rise slowly d/t orthostatic hypotension
- Decrease potassium rich foods in your diet
231
Beta-blockers: what do they do, medications, monitoring, patient education
**What do they do:** They block beta receptors on the heart reducing catecholamine (Epi, Nor epi, dopamine) stimulation thereby reducing heart rate and blood pressure.
**Medications:**
"-olol" -> atenolol, metoprolol
**Monitoring:**
- Heart rate, do not give if below 60 BPM
- Blood pressure, do not give if below 100 mmHg systolic
**Education:**
- Rise slowly d/t orthostatic hypotension
- May cause fatigue, weakness, depression, or sexual dysfunction
- **Do not stop abruptly** - can cause severe rebound tachycardia
- May mask hypoglycemic symptoms
232
How much should sodium be limited to in heart failure?
2g/day
233
How much fluid should individuals be restricted to with heart failure?
2L/day
234
What medications should be avoided in heart failure?
1) Acetaminophen
2) Spironolactone
3) Ibuprofen
4) Digoxin
**3)** Ibuprofen, it is a NSAID and they should be avoided as they can cause sodium and fluid retention
235
236
What is glaucoma?
**Increased intraocular pressure** that compresses the nerves, vessels, and photoreceptors in the eye causing a loss of vision at the **periphery toward the center**
237
What is more dangerous open-angle glacuoma or angle-closure glaucoma?
**Angle-closure glaucoma** as it causes complete and sudden vision loss d/t an obstruction of aqueous humor flow - **it is a medical emergency**
238
What are signs and symptoms of glacuoma?
**1)** blurry vision
**2)** halos around lights
**3)** loss of peripheral vision
**4)** poor dark vision
**5)** anxiety and fear
239
How is glaucoma diagnosed?
Through routine eye exams using tonometry to detect high pressure in the eye > 32 mmHg
240
When using eye drops, the nurse should educate patients to perform punctal occlusion, which is where you:
1) Close and squeeze your eyes hard to prevent the eye drops from leaking out
2) Place the eye drop right in the corner of the eye at the puncta or tear duct to allow drops to enter the eye
3) Place the knuckle or tip of your funger at the puncta to prevent eye drops from entering the tear duct
**3)** Place the knuckle or tip of your funger at the puncta to prevent eye drops from entering the tear duct
- Punctal occlusion should be done to prevent eye drops from entering systemic circulation
241
What should the nurse educate patients about when they are using eye drops for the first time?
**1)** Wash your hands before instilling eye drops
**2)** Do not touch the dropper to the eye surface
**3)** Wait 5-10 minutes betwen drops to prevent dilution
**4)** Hold pressure on the tear duct by performing punctal occlusion
**5)** Use your eye drops at the sime time each day
**6)** Your eyes may become blurry, sting, or burn temporarily after eye drops
242
What is the goal of prostalgandins, nitrix oxides, rho kinase inhibitors, cholinergic, and mitotic agents in glaucoma?
They help drain fluid from the eye
243
What is the goal of alpha agonists, beta-blockers, and carbonic anhydrase
They reduce the amount of aqueous humor in the eye
244
What is the overall goal of glacoma medications?
To lower the pressure in the eyes
245
What are ways to care for hospitalized individuals with vision loss?
**1)** Knock to announce yourself when entering the patient's area
**2)** Orient the patient to their room/environment
**3)** Provide clock face times for food locations on their plate
**4)** Do not move items or rearrange without their permission
**5)** Talk in a normal voice
**6)** Offer your arm when walking
246
What is sensorineural hearing loss, causes, and signs/symptoms?
**Sensorineural:** permanent hearing loss d/t damage to the cochlear hairs or auditory nerve
**Causes:** prolonged exposure to loud noises (plane engines, lawn mowers, loud music), loop diuretics, other medications
**S/S:** tinnitus, difficulty following conversations, hard to hear in loud environments
247
What is conductive hearing loss, causes, and signs/symptoms?
**Conductive:** temporary hearing loss d/t external ear conditions
**Causes:** cerumen build up, infection, object obstructin canal
**S/S:** obstruction, speaking softly, hearing better in one ear than the other
248
What should nurse education be about for hearing loss and prevention?
**1)** Wear hearing protection
**2)** Receive annual hearing screens
**3)** No q-tips
**4)** Do not place anything bigger than your pinky into the ear
**5)** Do not candle or engage in candling
**6)** Take care of your hearing aid
249
What are two safey considerations for those with hearing loss?
**1)** Fall risk d/t dizziness, unsteady, and fatigue
**2)** Home safety - visual indicators for alarms, phones, and doorbells
250
How can you improve communication for those with hearing loss?
**1)** Ensure their hearing aids are in
**2)** Make sure amplifier is working
**3)** Use white boards
**4)** Remove loud noises
**5)** Face them so that they can lip read
**6)** Speak in a low octave voice
**7)** Teach back education
**8)** Talk to them in a well-lit room
251
What are a couple of hearing aid tips?
**1)** Clean only the mold (nothing electronic) with mild soap and water
**2)** Place the hearing aid in the lowest setting
252
What is obstructive sleep apnea?
It is brief periods of **apnea lasting longer than 10 seconds** while asleep d/t the relaxation of neck muscles, soft palate, and tongue obstructing the airway while asleep causing intermittent hypoxia + impaired ventilation
253
What are some complications of obstructive sleep apnea?
**1)** Hypertension
**2)** Cardiovascular diseases
**3)** Stroke
**4)** Insulin resistance
**5)** Dementia
254
What are signs and symptoms of obstructive sleep apnea?
**1)** Fatigue
**2)** Daytime sleepiness
**3)** Headaches
**4)** Waking up gasping
**5)** Irritabiltiy
**6)** Memory loss
**7)** Overweight (cause + symptom)
**8)** Snoring
255
Is obstructive sleep apnea more common in men or women and in what age group?
More common in men
Higher in those 60+ y/o
256
What is the main priority in obstructive sleep apnea? What are three ways that this can be done?
Improving gas exchange
**1)** Changing sleeping positions
**2)** Losing weight
**3)** Continuous Positive Airway Pressure (CPAP)
257
What does a CPAP machine do?
CPAP provide continuous positive airway pressure, which means it continuous maintains a set pressure during inhalation and exhalation to keep the airway patent.
Make sure to the mask has a good fit.
258
A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis (DVT)?
1) An 18-year-old male athlete with a fractured clavicle
2) A 74-year-old male who smokes and has a fractured femur
3) A 36-year-old female with type 2 diabetes and fractured ribs
4) A 55-year-old female prescribed ibuprofen for osteoarthritis
**2)** A 74-year-old male who smokes and has a fractured femur
259
A client diagnosed with a large pulmonary embolism is started on oxygen but oxygen saturation has not significantly improved. What response by the nurse demonstrates an understanding of gas exchange and oxygenation in this situation?
1) “Breathing so rapidly interferes with oxygenation.”
2) “Maybe the client has respiratory distress syndrome.”
3) “The client needs immediate intubation and mechanical ventilation.”
4) The blood clot interferes with perfusion in the lungs.”
**4)** The blood clot interferes with perfusion in the lungs.”
260
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is the priority?
1) Assess for drainage from the site
2) Cover the insertion site with sterile gauze
3) Contact the primary health care provider.
4) Reinsert the tube using sterile technique.
**2)** Cover the insertion site with sterile gauze
261
The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate?
1) Reproducible leg pain with exercise
2) Unilateral swelling of affected leg
3) Decreased pain when legs are elevated
4) Pulse oximetry reading of 90%
**1)** Reproducible leg pain with exercise
262
A nurse is assessing a patient’s perfusion status. Which of the following findings is the best indicator of adequate tissue perfusion?
1) Blood pressure of 130/80 mmHg
2) Warm skin with brisk capillary refill
3) Urine output of 20 mL/hour
4) Heart rate of 110 beats per minute
**2)** Warm skin with brisk capillary refill
263
Which features will the nurse expect to be present in a client who has long-term chronic obstructive pulmonary disease? (Select all that apply.)
1) Poor gas exchange from decreased alveolar surface area
2) Increased anteroposterior chest diameter from air-trapping
3) Arterial blood gas value with increased PaO2 level
4) Hypercapnia from retained PaCO2
5) Respiratory acidosis with a low pH
1) Poor gas exchange from decreased alveolar surface area
2) Increased anteroposterior chest diameter from air-trapping
4) Hypercapnia from retained PaCO2
5) Respiratory acidosis with a low pH
264
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
1) Maintaining a semi-Fowler's position as often as possible
2) Administering oxygen via nasal cannula at 2 L/min
3) Helping the client select a low-salt diet
4) Encouraging the client to drink 2 to 3 L of water daily
**4)** Encouraging the client to drink 2 to 3 L of water daily
265
The nurse is caring for a patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following medications should the nurse administer first?
1) Tiotropium (Spiriva), an inhaled cholinergic antagonist
2) Salmeterol (Serevent), an inhaled long-acting beta2-agonist (LABA)
3) Albuterol (Proventil), an inhaled short-acting beta2-agonist (SABA)
4) Methylprednisolone (Solu-Medrol), an intravenous corticosteroid
**3)** Albuterol (Proventil), an inhaled short-acting beta2-agonist (SABA)
266
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration?
1) Troponin
2) ST segment
3) Heart rate
4) Myoglobin
**3)** Heart rate
267
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second. How should the nurse interpret this cardiac rhythm?
1) Ventricular tachycardia
2) Ventricular fibrillation
3) Atrial fibrillation
4) Sinus tachycardia
**1)** Ventricular tachycardia
268
The nurse is caring for a client who is suspected to have anemia. Which assessment finding does the nurse anticipate?
1) Difficulty sleeping
2) Shortness of breath
3) Chronic headaches
4) Warm hands and feet
**2)** Shortness of breath
269
A nurse is monitoring a patient after administering nitroglycerin. Which assessment finding requires the immediate intervention?
1) Heart rate of 82 beats per minute
2) Flushed, warm skin
3) Blood presure 88/48 mmHg
4) Complains of headache
**3)** Blood presure 88/48 mmHg
