RN has 65 yr old pt s/p acute MI, 3 days ago with tenderness and warmth in left calf, what is priority?

Perform neurovascular assessment of BLE

RN is teaching precipitating factors of stable angina, SATA

emotional or job stress, strenuous activity, smoking

Charge RN is assessing the hemodynamics of the patients in the unit, which patient requires immediate intervention?

Pt with GI bleed and a MAP of 58 mm Hg

UAP reports VS on 4 patients, who should the nurse go see first?

65 yr old S/P liver biopsy, tachycardia, 110 BPM

Pt is waiting for ablation; the RN observes this strip & notes that the P waves are not with the QRS, best intervention?

Notify cardiologist and prepare for temporary pacing

8 AM meds are due for you patients, who do you administer to first?

PRN Albuterol for a pt complaining of dyspnea

Four pts were in an MVA, who needs to be seen first?

Pt with BP of 90/70 and a deviated trachea

The RN is returning to get report 24 hrs later, on the 4 MVA pt's, who should they assess first?

Pt w/ O2 sat 90%, severe inspiratory pain and a lung contusion

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Answers

1
RN has 65 yr old pt s/p acute MI, 3 days ago with tenderness and warmth in left calf, what is priority?
Obtain VS and pulse ox reading
Perform neurovascular assessment of BLE
Ask how long the pt has been experiencing the symptoms
Monitor ECG and check for dysrhythmias
2
RN is teaching precipitating factors of stable angina, SATA
emotional or job stress
strenuous activity
antiplatelet therapy
smoking
3
RN is reviewing labs for a pt admitted with chest pain, which serum level requires immediate action?
BG 200
K+ 3.3
Troponin 0.7
Hct 34%
4
Pt admitted to ED to rule out MI, what tests would determine?
D-dimer
LDL levels
Troponin
Myoglobin
5
Charge RN is assessing the hemodynamics of the patients in the unit, which patient requires immediate intervention?
Pt with GI bleed and a MAP of 58 mm Hg
Pt that is septic r/t pneumonia, venous pressure 6 mm Hg
Pt s/p CABG with cardiac output of 5L/min
Pt with adrenal gland tumor with BP 168/95 mm Hg
6
UAP reports VS on 4 patients, who should the nurse go see first?
28 yr old endocarditis, HR 105 BPM
74 yr old diltiazem drip, Afib, 115 BPM
65 yr old S/P liver biopsy, tachycardia, 110 BPM
45 yr old acute pancreatitis, sinus tachycardia, 120 BPM
7
Pt is waiting for ablation; the RN observes this strip & notes that the P waves are not with the QRS, best intervention?
Document findings and continue to monitor
Call a code and begin chest compressions
Notify cardiologist and prepare for temporary pacing
Call a rapid response and prepare for cardioversion
8
Pt with chest pain r/t acute pericarditis, RN teaches that pain can be improved by?
Pursed lip breathing
Sitting up and leaning forward
Coughing and Deep breathing
Left lateral position
9
8 AM meds are due for you patients, who do you administer to first?
PO Aspirin for a pt with a HX of CAD and Ischemic Stroke
PRN Albuterol for a pt complaining of dyspnea
PO Metformin for a pt with elevated BG awaiting a cardiac catheterization
IV Morphine for a pt with terminal cancer, experiencing bone pain
10
The RN is administering 40 mg Furosemide, what should be assessed before administration of the medication? SATA
K+
BP
Liver Enzymes
BUN
11
Four pts were in an MVA, who needs to be seen first?
Pt with a concussion that was unconscious for 5 min
Pt with grossly swollen upper thigh and a BP of 80/60
Pt with BP of 90/70 and a deviated trachea
Pt with pain at thoracic spine and paralysis of both legs
12
Pt reports dizziness & diaphoresis. VS-BP 85/42, HR 180, RR 25, O2 91% RA, T 99, tele rhythm below, what should RN do?
Prepare for cardioversion
Administer IV epinephrine
Start chest compressions
Administer IV atropine
13
The RN is caring for a patient with decompensated heart failure w/ tachypnea & pink frothy sputum, after O2, administer?
Dopamine
Furosemide
Albuterol
Digoxin
14
The RN is returning to get report 24 hrs later, on the 4 MVA pt's, who should they assess first?
Pt with fx tibia, a cast, red skin around cast and swollen toes
Pt w/ pneumothorax, intermit bubbling in water seal chamber of chest tube
Pt w/ fractured pelvis and ecchymosis and bruising over pelvis area
Pt w/ O2 sat 90%, severe inspiratory pain and a lung contusion
15
Pt admitted for STEMI, what should the RN do first?
Assess for JVD
Assess heart and lung sounds
Attach Tele
Assess full vitals

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