MED SURG 201 PALS QUIZ 2
• Lab Values
o HR: 60-100BPM
o Stroke volume: the volume of blood pumped from the left ventricle per beat.
Stroke volume is calculated using measurements of ventricle volumes from
an echocardiogram and subtracting the volume of the blood in the ventricle at the
end of a beat (called end-systolic volume) from the volume of blood just prior to
the beat (called end-diastolic volume). End-Systolic volume – end-Diastolic
volume, volume ejected w each heartbeat, SV: amount of blood pumped from left
ventricle per beat
• Heart rate: contraction of heart in a min 60-100
• HF is indicated: w dyspnea, elevated hBNP
o hBNP <100=no HF, 100-300 HF is present, >300mild HF, >600 moderate HF,
>900 severe HF
o quiz1; hypokalemia can cause shallow respiration, dyspnea
o Q 2. Pt with HF, refused to eat and complaining of her nausea and vomiting.
What do you do first? Assess vitals
• Nursing care for HF pt: 10
o Monitor weight and I&O
o Assess vital signs: BP, SO2
o High fowler position
o Rest until pt is stable
o Check ABG and electrolytes> potassium if use diuretics
, o Conserve energy during care and ADLs
o Emotional support
o Admin prescribed O2/ 2L
o Assess med toxicity> digoxin toxicity:
o Maintain dietary restriction fluid and sodium restriction
• Right sided HF Cause:
o inadequate right cardiac output
o systemic venous congestion
o peripheral edema
• Risk factors RHF
o Left sided HF
o Right ventricular MI
o Pulmonary problems > COPD & pulmonary fibrosis
• Expected findings: Q 3select all
o JVD,
o ascending dependent edema (leg, ankle, sacrum),
o Weight gain
o Tachypnea due to respiratory distress,
o persistent cough,
o orthopnea
o polyuria at rest nocturia,
o abnormal abdominal distension (ascites)
, o nausea, anorexia,
o fatigue, weakness,
o hepatomegaly: liver enlargement and tenderness
• cause:
o pulmonary congestion: dyspnea, cough, bibasilar crackle. Q4
o Frothy sputum > blood tinged
o Altered mental status
o Symptoms of Organ failure such as oliguria
• Cardiogenic shock:
o Serious complication of pump failure
o After heart attack
o Often fetal if it is not treated immediately
o following MI
o injury to greater than 40% of left ventricle
• Findings:
o Tachycardia,
o hypotension,
o inadequate urinary output,
o altered level of consciousness,
o respiratory distress,
o crackle,
, o tachypnea,
o cool, clammy skin,
o decreased peripheral pulses,
o chest pain
• Assess:
o breath sound, crackle and wheezing, heart sounds,
• Monitor:
o continuous hemodynamic
o Admin O2
• Admin IV:
o morphine,
o diuretic,
o nitroglycerin to decrease preload
o vasopressors
o positive inotropes to increase cardiac output and maintain organ perfusion
• Acute pulmonary edema:
o life-threatening medical emergency
o respiratory distress and decrease venous return
• Findings:
o anxiety,
o tachycardia,
• Lab Values
o HR: 60-100BPM
o Stroke volume: the volume of blood pumped from the left ventricle per beat.
Stroke volume is calculated using measurements of ventricle volumes from
an echocardiogram and subtracting the volume of the blood in the ventricle at the
end of a beat (called end-systolic volume) from the volume of blood just prior to
the beat (called end-diastolic volume). End-Systolic volume – end-Diastolic
volume, volume ejected w each heartbeat, SV: amount of blood pumped from left
ventricle per beat
• Heart rate: contraction of heart in a min 60-100
• HF is indicated: w dyspnea, elevated hBNP
o hBNP <100=no HF, 100-300 HF is present, >300mild HF, >600 moderate HF,
>900 severe HF
o quiz1; hypokalemia can cause shallow respiration, dyspnea
o Q 2. Pt with HF, refused to eat and complaining of her nausea and vomiting.
What do you do first? Assess vitals
• Nursing care for HF pt: 10
o Monitor weight and I&O
o Assess vital signs: BP, SO2
o High fowler position
o Rest until pt is stable
o Check ABG and electrolytes> potassium if use diuretics
, o Conserve energy during care and ADLs
o Emotional support
o Admin prescribed O2/ 2L
o Assess med toxicity> digoxin toxicity:
o Maintain dietary restriction fluid and sodium restriction
• Right sided HF Cause:
o inadequate right cardiac output
o systemic venous congestion
o peripheral edema
• Risk factors RHF
o Left sided HF
o Right ventricular MI
o Pulmonary problems > COPD & pulmonary fibrosis
• Expected findings: Q 3select all
o JVD,
o ascending dependent edema (leg, ankle, sacrum),
o Weight gain
o Tachypnea due to respiratory distress,
o persistent cough,
o orthopnea
o polyuria at rest nocturia,
o abnormal abdominal distension (ascites)
, o nausea, anorexia,
o fatigue, weakness,
o hepatomegaly: liver enlargement and tenderness
• cause:
o pulmonary congestion: dyspnea, cough, bibasilar crackle. Q4
o Frothy sputum > blood tinged
o Altered mental status
o Symptoms of Organ failure such as oliguria
• Cardiogenic shock:
o Serious complication of pump failure
o After heart attack
o Often fetal if it is not treated immediately
o following MI
o injury to greater than 40% of left ventricle
• Findings:
o Tachycardia,
o hypotension,
o inadequate urinary output,
o altered level of consciousness,
o respiratory distress,
o crackle,
, o tachypnea,
o cool, clammy skin,
o decreased peripheral pulses,
o chest pain
• Assess:
o breath sound, crackle and wheezing, heart sounds,
• Monitor:
o continuous hemodynamic
o Admin O2
• Admin IV:
o morphine,
o diuretic,
o nitroglycerin to decrease preload
o vasopressors
o positive inotropes to increase cardiac output and maintain organ perfusion
• Acute pulmonary edema:
o life-threatening medical emergency
o respiratory distress and decrease venous return
• Findings:
o anxiety,
o tachycardia,
