Med Surge II - Test 2

  1. What is the nursing diagnosis for CABG post-op?
    Decreased cardiac output
  2. CABG-Post op:
    What are signs of Mediastinitis?
    • Fever > 4 days
    • Boggy sternum
    • Signs of infection at suture site
    • Elevated WBC
  3. CABG-Post op:
    What are signs of Postpericardiotomy syndrome?
    • Pericardial & pleural pain
    • Friction rub
    • Fever, elevated WBC, dysrythmias
  4. A patient has just underwent a CABG and there was a sudden cessation of previously heavy CT output, what should the nurse suspect?
    Cardiac Tamponade
  5. CABG-Post op:
    What are signs of Cardiac Tamponade?
    • Sudden cessation of CT output
    • JVD with clear lung sounds
    • Tachycardia
    • Hypotension
    • Muffled heart sounds
    • Diminished peripheral pulses
    • Pulsus paradoxus
  6. What should be immediately reported to a MD after a CABG?
    Chest tube outputof >150ml/hr
  7. Healthy Triglyceride levels in men?
    < 150
  8. Healthy Triglyceride levels in women?
    < 135
  9. Healthy Cholesterol levels?
    • < 200
    • LDL (0-130) - lower the better
    • HDL (>40) - higher the better
  10. T/F: Men have a greater chance of CAD until women reach menopause
  11. Chronic stable angina?
    • Chest discomfort precipitated by stress/exertion
    • *Relieved by rest and/or NTG*
    • Less than 15 min of duration
  12. Chronic Unstable angina?
    • chest pain > 15 min. duration
    • Poorly relieved by rest or NTG
  13. If someone is having a heart attack what should they do?
    Chew 325mg of Aspirin, rest & call 911
  14. How often can you administer NTG sublingually?
    Every 5 minutes - up to 3 times
  15. When should you notify position after taking NTG?
    If BP <100 mm HG or drop of 25 mm Hg - & lower head of bed and call doctor
  16. NTG Patch teaching?
    Remove 8-10 hours everyday to prevent tolerance
  17. Expected side effect of NTG?
    • Headache (back of head)
    • Hypotension
  18. NTG tablet patient teaching?
    • replace pills every 3-5 days
    • Store in dry, dark place
  19. When would you want to hold a Beta-Blocker and notify physician?
    • HR < 60 bpm
    • BP < 100 mm Hg
  20. If a patient comes in with chest pain what actions should the nurse take?
    • Pt. should be placed on a stretcher with HOB at level of comfort & do MONA
    • -Morphine (contraindicated in low BP & bradycardia)
    • -Oxygen 4L (>95% O2 sat)
    • -Nitroglycerin
    • -Aspirin (chew 325mg)
  21. ST Depression represents what?
  22. ST elevation represents what?
  23. What assessment finding would indicate thrombolytic therapy is needed?
    • ST Elevation
    • Continuous chest pain > 30 min unrelieved by NTG

    (most effective within 6 hrs of onset)
  24. What is the exclusion criteria for thrombolytic therapy?
    • Any condition predisposing hemorrhage
    • Active bleeding
    • Uncontrolled hypertension
    • CVA
  25. How do you know if Thrombolytic Threapy has worked?
    • Resolution of chest pain
    • ST segment return to baseline
    • Reperfusion dysrhythmias
    • Rapid rise in cardiac enzymes
  26. What does MOVE IT C stand for?
    • Monitor
    • Oxygen
    • Vital Signs
    • EKG Stat
    • IV Access
    • Treatment-thrombolytics
    • Chest x-ray within 30 min
  27. CKMB normal level:
  28. What is the normal range for troponin?
    <.35 mcg/L
  29. What is the normal range for myoglobin?
    <90 mcg/L
  30. An increase in cardiac enzymes is indicative of _______.
    Non stemi/unstable angina or that the clot has been dissolved
  31. If your pt's monitor is showing PVCs what do you need to watch for especially in the first hour?
    V fib
  32. What is a dysrhythmmia commonly follows an MI?
  33. Nursing interventions for Post procedure-cardiac cath (PCTA):
    • HOB 30 degree or less for 4-6 hr
    • maintain pressure dressing
    • avoid flexion of extremity for 12-24 hrs
  34. Complications of MI?
    S/S include: pericarditis with effusion, chest pain, dyspnea
    dressler's syndrome
  35. What is the nursing diagnosis for STEMI?
    ineffective tissue perfusion
  36. Who are beta blockers CI in?
    asthma patients
  37. What would you monitor after adminstering thrombolytic therapy?
    • Bleeding at IV site
    • Occult blood in urine, feces, emesis, etc.
    • H&H
    • neurological status (obtain baseline prior to adminstration)
  38. Thromobolytic post infusion nursing interventions :
    • bed rest for 6 hr
    • pressure at site after catheter removal
    • neuro checks
    • antiplatelets as ordered
  39. What drug should you stop before having a CABG?
Card Set
Med Surge II - Test 2