Cross your heart and hope (not) to die
A patient with atrial fibrillation has HR 160, BP 78/46, chest pain, and altered mental status. What is the priority intervention?
Synchronized cardioversion
You walk in your patient’s room who has COPD and you notice that their O2 is at 4LPM via NC and their SP02 is at 95%. What do you do next?
Drop the O2 to as low as possible while keeping the SP02 between 88%-92% and educate on pursed lip breathing techniques
A patient with severe vomiting has:
pH- 7.52
PaCO- 44
HCO- 34
What is the primary acid-base problem?
Metabolic alkalosis
A patient after a thyroidectomy develops:
What electrolyte imbalance should the nurse suspect, and what should they do next?
DX- hypocalcemia
-Notify provider and request calcium replacement orders
A patient had a stroke and has difficulty swallowing. The provider wants enteral nutrition. The patient is hemodynamically stable and does not need gastric decompression.
Which tube would be most appropriate, and why?
A Dobhoff tube because it is a small bore tube designed primarily for enteral feeding and medication administration.
An NG tube is larger and is commonly used when gastric decompression or suctioning is needed.
A 68 yo patient reports sudden crushing substernal chest pain radiating to the left arm, is diaphoretic and nauseated. BP is 88/54, HR 104, and SpO₂ is 94% RA. The 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. What should you do next?
DX- acute inferior STEMI with hypotension
-call code stemi
-apply O2
-place the patient on continuous cardiac monitoring -obtain/maintain IV access
(Avoid giving nitroglycerin- will make hypotension Worse)
You have four patients. Which one requires immediate attention?
A. COPD patient with SpO₂ 89% on their prescribed 2 L/min oxygen, awake and speaking comfortably.
B. Pneumonia patient with temperature 39.1°C and productive cough, but RR 20 and BP 118/70.
C. Asthma patient whose wheezing suddenly disappears, RR falls from 32 to 12, and who is becoming lethargic.
D. Post-op patient with mild dyspnea and HR 104 after walking to the bathroom.
C
A patient with COPD is increasingly drowsy.
pH-7.28
PaCO- 68
HCO- 30
What does this ABG show?
Respiratory acidosis with partial metabolic compensation
A patient with severe diarrhea has the following labs:
Na- 138
K- 2.4
Mg- 1.1
Ca- 8.4
The patient is experiencing frequent PVCs despite potassium replacement. Which electrolyte should the nurse be most concerned about correcting next, and why?
Mag
Normal mag levels help the body to retain K
A patient develops symptomatic complete heart block with a heart rate of 28/min. The patient is hypotensive and confused.
What device/intervention would the nurse anticipate first?
Answer:
Temporary pacing, such as transcutaneous or transvenous pacing, because the patient has an unstable bradyarrhythmia requiring immediate rate support.
A permanent pacemaker may be needed later, but can be scheduled for procedure when the patient is stable
An ICD is primarily used to treat/prevent life-threatening ventricular tachyarrhythmias (vtach/vfib) when the rhythm is reoccurring
A patient with severe heart failure suddenly becomes extremely short of breath. He is sitting upright, coughing up pink, frothy sputum, and has diffuse crackles. SpO₂ is 82%. What do you suspect and what should you do next?
DX- acute pulmonary edema
-Sit patient upright as far as possible
-Apply high flow O2
-Call rapid if patient doesn’t stabilize or notify provider for further orders
A mechanically ventilated patient suddenly becomes hypotensive with absent breath sounds on the right and tracheal deviation to the left. What is most likely happening and how do you treat?
Tension pneumothorax; immediate needle decompression
A patient with diabetic ketoacidosis has:
pH- 7.18
PaCO- 22
HCO- 8
The patient is breathing very rapidly and deeply.
What is happening, and why is the patient breathing this way?
Metabolic acidosis with respiratory compensation. The deep, rapid breathing is Kussmaul respirations, an attempt to eliminate CO₂ and raise the pH
A patient with heart failure is receiving diuretics. The patient becomes confused and then has a seizure.
Labs:
Na-116
K-3.8
Mg-1.9
Question:
What is the nurse's priority?
Protect the airway and patient from injury and immediately escalate care. Severe hyponatremia can cause cerebral edema and seizures. Anticipate carefully controlled sodium correction as ordered.
A patient is 8 hours post-op after thoracic surgery and has a chest tube connected to a drainage system. During your assessment, you notice the chest tube has drained 180 mL of dark-red fluid over the past hour, compared with 50 mL the previous hour. The patient’s HR is 104, BP is 108/66, RR is 22, and SpO₂ is 94%. The patient reports mild increased shortness of breath, and breath sounds are decreased on the operative side. When assessing the chest tube system, you note tidaling in the water-seal chamber and intermittent bubbling when the patient coughs. The suction chamber is at the prescribed level, the tubing is connected and free of kinks, and the dressing is clean, dry, and intact.
What do you do next?
Continue to closely monitor, reassess and trend the chest tube output and respiratory status as well as VS.
The increasing bloody drainage, new shortness of breath, and decreased breath sounds require further assessment, even though the patient is currently hemodynamically stable
A patient who had a myocardial infarction 2 days ago suddenly develops severe hypotension, jugular venous distention, muffled heart sounds, and increasing tachycardia. The lungs are relatively clear. What do you suspect and how do you treat?
Cardiac Tamponade
Patient is at risk for going into obstructive shock. Assess your patient to determine if they are stable or not.
Stable?- Notify providers immediately and f/u asap
Untable?- Call Rapid
A patient with sepsis develops severe respiratory distress. Despite receiving supplemental oxygen, SpO₂ remains 82%. Bilateral crackles are present, and a chest X-ray shows diffuse bilateral infiltrates. There is no evidence of left-sided heart failure. What dx do you suspect?
DX- ARDS (acute respiraptors distress syndrome)
A patient has:
pH- 7.37
PaCO- 50
HCO- 32
The patient has a history of chronic COPD.
How should the nurse interpret this?
Fully compensated respiratory acidosis
(Chronic cO2 retention and renal compensation)
A patient with renal failure has:
Na- 150
mag- 1.0
K- 7.2
Ca- 7.1
Phos- 4
The ECG shows widening QRS complexes. The patient reports tingling around the mouth.
Which electrolyte problem is the immediate prIority and why?
K. The severe potassium elevation with ECG changes places the patient at immediate risk for fatal dysrhythmia. The patient needs emergency treatment to stabilize the cardiac membrane and lower potassium.
A patient has end-stage heart failure and is awaiting a heart transplant. Despite maximal medical therapy, the patient's heart cannot pump enough blood to maintain adequate circulation. What device might be implanted to support the patient's cardiac output while they wait for a transplant?
LVAD (Left ventricular assist device)
A patient with a large anterior MI is pale and anxious. BP is 78/46, HR 124, urine output is 15 mL/hr, and the skin is cool and clammy. Crackles are present bilaterally. What do you suspect and how do you treat?
Dx: cardiogenic shock (Low BP and poor perfusion)
-Position trend?
-Apply O2
-IV access/fluids
-Notify provider immediately and call rapid if appropriate
A patient with COPD exacerbation is severely short of breath.
RR- 32
SpO- 84%
PaCO- 68 mmHg
ph - 7.25
The patient is awake, cooperative, and able to protect their airway.
Which type of noninvasive ventilation would the nurse anticipate, and why?
BiPAP.
BiPAP provides two levels of pressure, a higher pressure during inspiration and lower pressure during expiration. This helps improve ventilation and CO2 removal, making it particularly useful for hypercapnic respiratory failure such as a COPD exacerbation.
CPAP provides essentially one continuous pressure and is more commonly used to improve oxygenation and maintain airway patency (For OSA mainly)
A patient with sepsis has:
pH- 7.19
PaCO- 55
HCO- 20
What does this ABG indicate?
Mixed respiratory and metabolic acidosis
A patient who has been NPO for several days is started on tube feeding. Two days later, the patient becomes increasingly weak and confused.
Labs show:
Phosphorus- 1.1
K- 3.2
Mag- 1.5
Na- 138
The patient develops shallow respirations and increasing difficulty breathing. Which electrolyte imbalance is most concerning, and why? What should the nurse do next?
Severe hypophosphatemia is the priority.
Phosphate is needed for ATP production and muscle function. Severe deficiency can cause respiratory muscle weakness and respiratory failure, particularly in a patient at risk for refeeding syndrome.
The nurse should immediately notify the provider, assess respiratory status, place the patient on continuous vs monitoring, and anticipate phosphate replacement with careful management to prevent refeeding syndrome
A patient with severe heart failure has a Swan-Ganz catheter in place. The nurse is monitoring the patient's hemodynamic status.
The nurse notes a PAWP (wedge pressure) of 24 mmHg.
The patient is also short of breath and has crackles in both lungs.
What does the elevated PAWP most likely indicate?
Increased left sided heart pressures and fluid backing up into the lungs, consistent with left-sided heart failure/pulmonary congestion