NR 452 Simulation Questions & Answers

1. What key priority assessment findings are usually seen in left-sided heart failure? How do these findings differ from right-sided heart failure? Left sided heart failure: the left side of the heart cannot pump the blood out of the heart so blood starts to back up into the lungs. Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure. Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation. Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange. Right-Sided Heart Failure When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates. The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the venous system. 2. Identify two common medication classes used to treat left-sided heart failure. What are two nursing considerations for each identified classification of medication? ACE Inhibitors and Beta-blockers (caution with asthmas, blood pressure, heart rate, hold less than 60), Digoxin can both be used. Nursing considerations when giving medications such as ACE Inhibitors nursing interventions are; • Take complete health history of patient. • Monitor blood pressure and pulse frequently to avoid initial dose hypotension. • Daily check the weight and fluid overload. • Check the s/s of angioedema (swelling of face and extremities) • Monitor BUN, serum potassium, creatinine, AST, ALT, serum bilirubin level • ACE inhibitors may cause false urine acetone level • Monitor kidney function • Hyperkalemia Secondly, nursing interventions when giving the patient a Beta Blocker; • Inquire patient’s complete health history including allergies, diabetes or any respiratory diseases • Monitor blood pressure and pulse prior administration of medicine. If blood pressure and pulse is not in normal range inform the health practitioner. • Observe daily intake an output of fluid. Check body weight. • If patient is on parenteral drug, then check blood pressure and pulse frequently. • Patient with respiratory disease specially with asthma or COPD should be closely monitored for sign and symptoms. • Observe lab determining electrolytes, BUN, creatinine levels. • In diabetic patient observe hypoglycemic effects • Potassium levels Digoxin: Therapeutic Level: 0.5 – 2 Apical pulse: 1 min Hold less than 60 3. How do cultural differences impact nurses in teaching diet and nutrition? What is cultural humility? Food preferences and preparation methods often are culturally influenced. Certain food groups serve as staples of the diet based on culture and remain so even when members of that culture are living in a different country. Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions. Dietary teaching must be individualized according to cultural values about the social significance and sharing of food. Cultural humility is a process that ensures that healthcare professionals learn about other cultures and are sensitive to cultural differences. 4. What are two nursing considerations in prioritizing and deciding placement location of a peripheral IV in heart failure? Peripheral venous access should be obtained using an 18 to 22-gauge IV in the upper extremity. 7-French pulmonary artery (PA) catheter was advanced into the PA using standard technique under fluoroscopic guidance. The tip of the PA catheter was positioned in the PA with the CVP port in the right atrium or superior vena cava. 5. What are common signs and symptoms of acute infection in the elderly, and what two priority nursing interventions would you employ? Loss of appetite, decline in functioning, mental status changes, incontinence and falls are all common first signs of acute infections. Nursing interventions for acute elder infections; • Orient patient to surroundi