NCLEX Practice Question of the Day: Prioritization, Cardiac

A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing actions should take priority?

a. A complete history with emphasis on preceding events

b. An electrocardiogram (EKG)

c. Careful assessment of vital signs

d. Chest exam with auscultation

 

Answer in the comments.

More practice NCLEX-RN questions.
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Medical-Surgical: Left versus Right Heart Failure

LEFT HEART FAILURE

• left = “lungs” = respiratory symptoms
• blood backs up into the lungs due to failure of the left side of the heart
• classic symptoms: dyspnea, crackles in lungs

RIGHT HEART FAILURE

• blood backs up into the periphery due to failure of the right side of the heart
• classic symptoms: edema, jugular vein distention (JVD), hepatomegaly, splenomegaly

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Medical-Surgical: Diabetes Mellitus

Diabetes Mellitus (DM), otherwise known as diabetes, is a “group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin” (American Diabetes Association [ADA], 2012).

Types of Diabetes

• Type I – autoimmune destruction of insulin-producing beta cells; present at birth; may also be referred to as insulin-dependent DM
• Type II – characterized as insulin resistance or decreased ability of pancreas to produce insulin; occurs later in life; may also be referred to as non-insulin-dependent DM
• Gestational – present during pregnancy

How is DM diagnosed?

• less than 100 mg/dL = normal
• 100 to 126 mg/dL impaired fasting glucose (IFG) = prediabetes
• greater than 126 mg/dL = diabetes
• two hour oral glucose test > 200 with glucose load of 75g
• diagnosis of DM must be confirmed on a subsequent day with FBS, TFG or 2 hour glucose tolerance test

Glycosylated hemoglobin, also known as A1C, measures glucose control over the past 3 months.

How do we manage DM?

• Nutrition:
  – For Type I DM, insulin doses are balanced with usual food intake and exercise. Patient must be consistent with the timing of insulin administration and amount of food consumed (especially carbohydrates [CHO]).
  – For Type 2 DM, initial dietary management aimed at decreasing calories, fats and simple sugars. Weight loss may help improve glycemic control (recommended weight loss of 5-7%).
• Exercise may help decrease insulin resistance, lower blood glucose levels directly, improve circulation and muscle tone
  – a caution about exercise and DM: AVOID exercise if hyperglycemia is present WITH ketosis
  – exercise lowers blood glucose levels for about 48 hours after activity
  – patients should exercise for 1 hour after a meal or have a 10-15g CHO snack
  – patients must check their blood glucose before, during and after exercise
  – *do NOT exercise if blood glucose is less than 100
• Drug therapy:
  – insulin: given subcutaneously or IV (only Regular can be given IV); different types of insulin with different onsets and peaks**; abdomen is highest rate of absorption followed by the arm, thigh then buttocks
  – oral agents: sulfonylureas, meglinitides, metformin

**Insulin types, peaks, onsets and durations

Complications of DM

• Hypoglycemia
  – caused by too much insulin or by too much exercise compared to the amount of food eaten
  – BG < 70 mg/dL
  – symptoms: “wet and shaky” – cold sweats, weakness, irritability, pallor, increased HR, confusion, fatigue
  – treatment: give a fast acting CHO; when symptoms improve, give a long lasting CHO; Glucagon injection also given
• Diabetic Ketoacidosis
  – defined as a profound deficiency in insulin leading to an extremely elevated BG level 
  most likely occurs in type I DM, but can occur in type II DM during stress or illness
  – symptoms: polyuria, dry mouth, thirst, restlessness, sunken eyeballs, Kussmaul respirations, CNS changes, fruity breath, ketonuria
  – treatment: 1.) low dose regular insulin (0.1 units) in normal saline (NS) IV; 2.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 3.) replace electrolytes; 4.) prevent cerebral edema and monitor VS, I&O and cardiac status
• Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
  – a life-threatening syndrome that occurs mainly in type II DM and leads to an extremely elevated BG level
  – symptoms: polyuria, dehydration; but NO ketones
  – treatment: 1.) rapid replacement of fluid via IV NS or 1/2NS; 2.) administer regular insulin via IV; 3.) when BG reaches 250, glucose is added to the IV to prevent hypoglycemia; 4.) replace electrolytes and monitor VS, I&O and cardiac status

Complications associated with insulin therapy

• Allergy – now rare due to use of human insulin
• Lipodystrophy – occurs if the same injections sites are used subsequently; hypertrophy may also occur is a site is not used for 6 months; this is also rare with human insulin
• Somogyi effect – body abnormally overreacts to hypoglycemia occurring at night or during sleep by increasing BG levels; elevated BG noted on morning BG checks and is associated with undetected hypoglycemia during sleep; treatment with less insulin
• Dawn phenomenon – hyperglycemia is present in the morning due to counter-regulatory hormones released in the predawn hours; treatment by adjusting timing of insulin or increasing insulin

Content Sources:
American Diabetes Association.
Medical-Surgical Nursing: Assessment and Management of Clinical Problems.
Diabetes Self-management.
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Psych Medications: Mood Stabilizers

Anti-manic and Mood Stabilizing drugs (Lithium, Depakote, Lamictal, Tegretol, Trileptal)

• LITHIUM is the drug of choice for controlling manic episodes
• lithium has a narrow therapeutic index (~0.6-1.2), familiarize yourself with the different LEVELS OF TOXICITY
• normal SE of lithium include fine tremors, mild thirst, mild nausea and general discomfort – if they persist, may indicate toxicity
• remember that DEHYDRATION (excess nausea, diarrhea, sweating, diuretics) may cause lithium TOXICITY
• SE of toxicity include coarse tremors, persistent GI upset, confusion, muscle irritabbility, ECG changes, incoordination
• lithium level of > 2.5 may = DEATH
• Tegretol may cause agranulocytosis – monitor WBCs
• Lamictal may cause Steven-Johnson’s – monitor platelets
• Depakote may cause hepatotoxicity and thrombocytopenia – monitor LFTs and platelets

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Psych Medications: Benzodiazepines

Benzodiazepines/Non-benzodiazepine Anxiolytics (Ativan, Klonopin, Valium, Xanax, Librium, Buspar, Inderal)

• [Val and Xan the Klo Ind the Bus] “Val and Xan the Klown In the Bus”
• benzos increase GABA, have rapid onset
• few drug interactions, but can interact with other CNS depressants (alcohol) and manifest as sedation or death
• there is potential for ABUSE, be cautious when giving to patients with history of substance abuse
• benzos must be tapered to lessen S&S of withdrawal (fatigue, irritability, insomnia, tremors)
• BUSPAR is a special drug: takes a while to work, so often is taken with a benzo while waiting for therapeutic effect; no potential for abuse; high cost

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Maternal/Child Health (OB): Fetal and Maternal Assessment Techniques

I. ULTRASOUND (US)

• used during first trimester to assess: # of fetuses, gestational age, uterine abnormalities, fetal cardiac movement and rhythm
• used during second and third trimester to assess: size-date discrepancies, amniotic fluid volume, uterine anomalies, amniocentesis results, gestational age, fetal viability, placenta location and maturity
• nursing implications: patient may need to maintain a full bladder prior to US if in the first or second trimester for the uterus to be observable (not needed for transvaginal US)
• no known complications

II. CHORIONIC VILLI SAMPLING (CVS)

• at 8 to 12 weeks gestation, a small piece of villi is removed guided under an US
• determines genetic diagnosis in the first trimester
• nursing implications: lithotomy position, patient may feel sharp pain when catheter inserted
• complications: spontaneous abortion

III. AMNIOCENTESIS

• at 14-16 weeks, amniotic fluid sample removed from uterus
• used to assess: genetic diagnosis, fetal lung maturity, fetal well-being
  – genetic disorders: trisomies, metabolic disorders, neural tube defects
  – fetal lung maturity: L:S ratio (2:1) and presence of prostaglandins (PG) after 35 weeks is most accurate determination
  – fetal well-being: bilirubin delta optical density, meconium may indicate fetal distress
• nursing implications: supine position, use of Betadine to sterilize site, label samples, monitor FHR 1 hour after procedure; ***if amniocentesis is done in early pregnancy, bladder must be FULL; it done in late pregnancy, bladder must be EMPTY to prevent puncture
• complications: spontaneous abortion, fetal injury, infection

IV. ELECTRONIC FETAL MONITORING (EFM)

• variables of EFM:
  – contractions – duration, frequency, intensity
  – baseline fetal heart rate (FHR) – 110-160, measured over 10 minutes
• variability: absent, minimal (< 5 bpm) , moderate (6-25 bpm), marked (>25 bpm)
• VEAL CHOP
• warning signs: absent or minimal FHR, bradycardia (< 110), tachycardia (>160), variable decelrations
• emergent signs: severe variable decelrations (FHR <70, lasting > 30-60s), late decelerations

V. NONSTRESS TEST (NST)

• assesses fetal response to movement which can determine fetal well-being in high-risk pregnancies
• healthy “reactive” sign: fetus responds to movement by a fetal heart rate (FHR) acceleration of 15 beats, lasting 15 seconds after movement, occuring twice in a 20 minute period
• nursing implications: apply fetal monitor, give handheld event marker to mother and instruct her to push button whenever she heels movement, it may also be recorded on FHR strip, *if there is not fetal movement, assume that the fetus is sleeping and stimulate it through sound or palpation or have mother move it and begin test again

VI. CONTRACTION STRESS TEST (CST) or OXYTOCIN CHALLENGE TEST (OCT)

• assesses fetal response to low oxygen supply during induction of contractions (through nipple stimulation or Oxytocin)
• nonreassuring “bad” sign: late decelerations = placental insufficiency!
• contraindications: rupture of membranes (ROM), prematurity, hydramnios, multiple gestation, placenta previa, previous uterine classical scar
• nursing implications: place external monitors of abdomen (ultrasound and tocodynanometer); record a 20 second baseline strip to determine reactivity (fetal well being) and presence/absence of contractions; for nipple stimulation, have patient use warm wet washcloths to roll nipple of one breast for 10 minutes and rol both if contractions don’t start within 10 minutes; oxytocin infused if no contractions after nipple stimulation
• complications: hyperstimulation or tetany (contractions over 90 seconds OR contractions with less than 30 seconds in between) R/T overstimulating nipples
• REMEMBER: a NEGATIVE test = GOOD (fetal well being)

VII. BIOPHYSICAL PROFILE (BPP)

• ultrasound used to evaluated fetal health by assessing:
  1.) fetal breathing movements (FBM)
  2.) gross body movements (GBM)
  3.) fetal tone (FT)
  4.) reactive fetal heart rate (nonstress test)
  5.) qualitative amniotic fluid volume (AFV)
• each variable = 2 points for a normal response; 0 points for an abnormal (either 2 OR 0)
• nursing implications: prepare, inform, provide support; teach patient that a LOW score = fetal compromise and needs to be assessed further
• a score of 8-10 = fetal well-being

VIII. FETAL PH BLOOD SAMPLING

• determiens true acidosis when nonreassuring fetal heart rate is noted (tachycardia not related to maternal variables, decreased variability not related to nonasphyxial causes, severe variable decels unresponsive to treatment, late decels)
• only performed in intrapartum period
• sample taken from the presenting part (breech or scalp) when membranes have ruptured and cervix dilated to 2-3cm

Image Source: #1, #2, #3, #4, #5, #6, #7,
Content derived from HESI Comprehensive Review for the NCLEX-RN Examination.

Management: What Can the Licensed Vocational Nurse (LVN) Do and Not Do?

LVNs CAN:

• CAN make focused assessments
• CAN administer some IVPB, PO, IM, subcut, ID, suppository, eye/ear/nose medications
• CAN perform dressing changes
• CAN catheterize
• CAN help with basic hygiene
• CAN employ clinical problem solving
• CAN observe a patient intervention (eg: pursed-lip breathing, incentive spirometer)
• CAN teach standardized information (eg: how to apply a nicotine patch)
• CAN collect data about a patient’s response to certain medications
• CAN reinforce teaching

LVNs CANNOT:

• CANNOT make initial or comprehensive assessments
• CANNOT administer IV push medications, antineoplastics, strong antibiotics, experimental medications
• CANNOT hang blood
• CANNOT do initial teaching

*** Please NOTE: the scope of practice for the LVN/LPN varies from state to state and also depends on their facility’s policies and procedures. Refer to your state’s Board of Nursing (BON) for a more detailed description of the scope of practice for licensed nurses. 

Content Source.
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Psych Medications: Antidepressants

I. Selective Serotonin Re-uptake Inhibitors – SSRIs (Lexapro, Celexa, Prozac, Paxil, Zoloft, Luvox)

• [Luv Zolo Proz, Lexa Cel Pax] “Love solo pros. Lexa sells packs.”
• SSRIs are FIRST LINE for depression
• has fewer side effects than TCAs or MAOIs
• no anticholinergic side effects, usual S&S include nausea, insomnia, sexual dysfunction

II. Atypical Antidepressants (new generation) (Cymbalta, Desyrel, Effexor, Remeron, Wellbutrin, Pristiq)

• [Cymba Des Well Effex. Remer is imPrist] “Cymba does well effects. Rem is impressed.”
• DESYREL can also be used for insomnia
• EFFEXOR and CYMBALTA may cause HTN
• CYMBALTA also used for neuropathic pain
• WELLBUTRIN also used for smoking cessation

III. Tricyclic Antidepressants (Elavil, Anafranil, Norpramin, Tofranil, Vivactil, Pamelor, Sinequan)

• Sounds like female names: Ela, Ana, Pam, Viv …; some end in -FRANIL or -IL
• may take about 1-3w for effect and 6-8w for max response
• have strong ANTICHOLINERGIC EFFECTS, so use with caution in elderly patients or patients with constipation, glaucoma or BPH
• these medications also have strong CARDIOTOXIC effects
• NORPRAMINE has low anticholinergic effects, which would be appropriate for the above
• once daily dosing at bedtime helps to promote sleep through sedation effects and reduce daytime sleepiness
• check the patient for HOARDING, especially if they are at RISK FOR SUICIDE

IV. Monamine Oxidase Inhibitors (MAOIs) (Nardil, Marplan, Parnate, EMSAM-patch)

• [PaNaMA] or [No Popular Meds (N.P.M.)]
• only used as a 2nd or 3rd choice for treatment of depression b/c of dietary restrictions and SE
• dietary restriction of foods high in TYRAMINE (dried fruits, almost all cheeses, processed meats, soy products, avocados)

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Critical Care: Emergency Medications

I. SODIUM CHANNEL BLOCKERS – ↓ conduction velocity in the atria, ventricles, His-Purkinje

• Class 1A: Norpace/disopyramide, Pronestyl/procainamide, Quinora/quinidine
  – action: delays repolarization
  – effect on EKG: wide QRS, prolonged QT
• Class 1B: Xylocaine/lidocaine, Mexitil/mexiletine, Dilantin/phenytoin
  – action: accelerates repolarization
  – effect on EKG: little to no effect
• Class 1C: Tambocor/flecainide, Rythmol/propafenone
  – action: decreases impulse conduction
  – effect on EKG: pronounced prodysrhythmic actions, wide QRS, prolonged QT

II. BETA ADRENERGIC BLOCKERS

• Tenormin/atenolol, Coreg/carvedilol, Brevibloc/esmolol, Lopressor/metropolol, Betapace/sotalol
  action: ↓ automaticity of SA node, ↓ conduction velocity of AV node, ↓ atrial and ventricular contractility
  effect on EKG: bradycardia, prolonged PR, AV block

III. POTASSIUM CHANNEL BLOCKERS

• Cordarone/amiodarone, Bretylol/bretylium, Tikosyn/dofetilide, Corvert/ibutilide, Betapace/sotalol
  action: delay repolarization, resulting in prolonged action potential and refractory period
  effect on EKG: prolonged PR and QT, wide QRS, bradycardia

IV. CALCIUM CHANNEL BLOCKERS

• Cardizem/diltiazem, Calan/verapamil
  action: ↓ automaticity of SA node, delay AV node conduction, ↓ myocardial contractility
  effect on EKG: bradycardia, prolonged PR, AV block

V. OTHER

• Adenocard/adenosine, Lanoxin/digoxin, Magnesium
  action: ↓ conduction through AV node, ↓ automaticity of SA node
  effect on EKG: prolonged PR, AV block

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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.

Critical Care: Mechanical Ventilator Basics

I. MODES OF VENTILATION

• Controlled: ventilator does the work of breathing (WOB) FOR the patient
• Assist-control: patient and ventilator share WOB, patient initiates a spontaneous breath and a tidal volume is delivered
• Synchronized Intermittent Mandatory Ventilation (SIMV): patient receives a preset tidal volume at a preset frequency, synchronous with the patient’s own breathing; patient can still breathe spontaneously in between ventilator breaths
• Pressure support ventilation (PSV): positive airway pressure (PAP) applied during inspiration; patient must be able to initiate a spontaneous breath
• Pressure-control inverse ratio ventilation (PC-IRV): prolonged PAP applied to increase inspiratory time and decrease expiratory time; normal inspiration/expiration (I:E) ratio is 1:2, with PC-IRV it is reversed to 2:3, 3:1, 4:1, etc1

II. VENTILATOR SETTINGS

• Rate (f) – number of breaths per minute (usual: 6-20)
• Tidal volume (Tv) – volume of air delivered with each breathe (usual: 6-10 mL/kg)
• Fraction of Inspired Oxygen (FiO2) – oxygen concentration (usual: 21%-100%)
• Positive End-Expiratory Pressure (PEEP) – positive pressure applied at the end of expiration (usual 5 cm H2O)
• Pressure support – positive pressure applied to keep airway open and facilitate inspiration (usual: 6-18 cm H2O)
• I:E ratio – inspiration:expiration ratio (usual: 1:2, 1:1.5), if IMV desired – 2:1, 3:1

III. VENTILATOR ALARMS

• High pressure alarm: kinking of the tubing, patient biting on endotracheal (ET) tube, secretions pooling in tubing, patient “fighting” the ventilator, bronchospasms, pulmonary edema
• Low pressure alarm: air leak from tube, ET tube cuff has deflated, total or partial extubation,

IV. PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA (VAP)

• Head-of-bed (HOB) elevated at minimum, 30-45 degrees
• NO routine changes of ventilator circuit tubing
• Use of an ET tube with dorsal lumen to facilitate suctioning
• Hand hygiene

V. WEANING PARAMETERS

• Negative Inspiratory Force (NIF) = 20-30
• Minute ventilation (Ve) = < 10 L/min
• Pressure of carbon dioxide (PaCO2) = 35-45 (or within normal limits [COPD patients])
• Pressure of oxygen (PaO2) = 60+
• Fraction of inspired oxygen (FiO2) = 50% or less
• Positive end-expiratory pressure (PEEP) = < 5
• Pressure support ventilation (PSV) = 10 or less

VI. COMPLICATIONS OF MECHANICAL VENTILATION

• Decreased cardiac output due to increase intrathoracic pressure resulting from high PEEP
• Barotrauma/volutrauma due to over distension of the lungs from high inspiratory pressures or high PEEP; can lead to pneumothorax
• Hypo/hyperventilation which can lead to acid base imbalances
• Ventilator-associated pneumonia (VAP)
• Fluid and electrolyte imbalances due to low cardiac output, low kidney perfusion

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Content derived from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 8th Edition.