High Acuity Nursing Exam 1: Cardiac – Questions &
Accurate Solutions
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Practice questions for this set
Learn 1 /7 Study using Learn
-explain procedure
-premedicate pt
-VS, IV, pulse ox
-continuous monitoring of ABCs
-monitor heart rhythm
-document procedure
Choose an answer
clinical guidelines for management of nursing management for electrical
1 2
pain cardioversion
3 indications for calling a RRT 4 PCA pumps are best suited for
Don't know?
Terms in this set (118)
,clinical guidelines for management of -assess and treat promptly (pain is what the patient
pain says it is)
-use valid and reliable pain assessment tools
-document findings
-engage patient in management plan
-provide preemptive treatment
-reassess and treat to meet patient's needs
-institute quality improvement plan r/t practice and
outcomes
assessment of pain -precipitating cause
-severity or symptoms associated with the pain
-location and radiation
-duration
-quality
-alleviating or aggravating factors
opioid with the fastest onset fentanyl
opioid with the longest duration morphine
PCA pumps are best suited for -elective surgery
-large surgical or traumatic wounds
-normal cognitive fx
-normal motor skills
agitation s/s -hyperactive psychomotor functions
-tachycardia
-HTN
agitation management -sedatives to limit hyperactive psychomotor
functions (use a low dose)
-benzodiazepines
-propofol and dexmedetodine (preferred for
mechanically ventilated patients)
-titrated to an end point using a scale
, delirium s/s -key word: inattention
-acutely changing mental status
-disorganized thinking
risk factors in ICU for delirium -coma
-preexisting dementia
-history of HTN
-alcoholism
-high severity of illness at admission (hypoxemia,
metabolic disturbances, electrolyte imbalances, head
trauma)
ABCDE bundle for preventing delirium -awakening
-breathing coordination
-choice of sedation
-delirium monitoring
-early mobility and exercise
types of delirium and their s/s -hyperactive: agitated, combative, disoriented
-hypoactive: quiet delirium
-mixed: fluctuating between the two
delirium txmt -drug of choice is haloperidol (neuroleptic agent)
because it produces mild sedation w/o analgesia or
amnesia and it has few anticholinergic and
hypotensive side effects
-intermittent IV route preferred in critically ill pt
because faster absorption and fewer side effects
indications for calling a RRT -threatened loss of airway
-RR less than 8 or more than 28
-HR less than 40 or more than 130
-SBP less than 90 or more than 180
-urine output less than 50 ml over 4 hours
-spo2 less than 90
-any pt the nurse is worried and concerned about
-altered mental status
-chest pain unrelieved by nitro
-uncontrolled pain
Accurate Solutions
Save
Practice questions for this set
Learn 1 /7 Study using Learn
-explain procedure
-premedicate pt
-VS, IV, pulse ox
-continuous monitoring of ABCs
-monitor heart rhythm
-document procedure
Choose an answer
clinical guidelines for management of nursing management for electrical
1 2
pain cardioversion
3 indications for calling a RRT 4 PCA pumps are best suited for
Don't know?
Terms in this set (118)
,clinical guidelines for management of -assess and treat promptly (pain is what the patient
pain says it is)
-use valid and reliable pain assessment tools
-document findings
-engage patient in management plan
-provide preemptive treatment
-reassess and treat to meet patient's needs
-institute quality improvement plan r/t practice and
outcomes
assessment of pain -precipitating cause
-severity or symptoms associated with the pain
-location and radiation
-duration
-quality
-alleviating or aggravating factors
opioid with the fastest onset fentanyl
opioid with the longest duration morphine
PCA pumps are best suited for -elective surgery
-large surgical or traumatic wounds
-normal cognitive fx
-normal motor skills
agitation s/s -hyperactive psychomotor functions
-tachycardia
-HTN
agitation management -sedatives to limit hyperactive psychomotor
functions (use a low dose)
-benzodiazepines
-propofol and dexmedetodine (preferred for
mechanically ventilated patients)
-titrated to an end point using a scale
, delirium s/s -key word: inattention
-acutely changing mental status
-disorganized thinking
risk factors in ICU for delirium -coma
-preexisting dementia
-history of HTN
-alcoholism
-high severity of illness at admission (hypoxemia,
metabolic disturbances, electrolyte imbalances, head
trauma)
ABCDE bundle for preventing delirium -awakening
-breathing coordination
-choice of sedation
-delirium monitoring
-early mobility and exercise
types of delirium and their s/s -hyperactive: agitated, combative, disoriented
-hypoactive: quiet delirium
-mixed: fluctuating between the two
delirium txmt -drug of choice is haloperidol (neuroleptic agent)
because it produces mild sedation w/o analgesia or
amnesia and it has few anticholinergic and
hypotensive side effects
-intermittent IV route preferred in critically ill pt
because faster absorption and fewer side effects
indications for calling a RRT -threatened loss of airway
-RR less than 8 or more than 28
-HR less than 40 or more than 130
-SBP less than 90 or more than 180
-urine output less than 50 ml over 4 hours
-spo2 less than 90
-any pt the nurse is worried and concerned about
-altered mental status
-chest pain unrelieved by nitro
-uncontrolled pain
