Progressive Care Nursing PCCN
Progressive Care Nursing Review PCCN
A patient who was admitted 3 days ago with a large myocardial infarction now reports dizziness and dyspnea. The patient is diaphoretic and ashen with a new holosystolic murmur. The nurse anticipates workup and treatment for
A. blunt cardiac injury.
B. myocardial infarct extension.
C. papillary muscle rupture.
D. complete heart block.
Answer: C. papillary muscle rupture.
Following myocardial infarction (MI), occlusion of the left anterior descending, circumflex, or posterior descending artery can impair flow to the mitral papillary muscles. The resultant ischemia can lead to complete rupture of one or more of the mitral valve leaflets, a phenomenon that typically occurs 2-7 days post infarct. The patient will present with signs of severe mitral regurgitation, such as hypotension and pulmonary edema, and will progress to cardiogenic shock. A new holosystolic murmur is present in about 50% of patients; others have no murmur or one that is very soft. Thoracic echocardiogram will confirm the diagnosis and immediate treatment is focused on reducing afterload and augmenting cardiac output. Patients urgently require ICU transfer and surgery to repair or replace the mitral valve.
When administering drugs to a patient experiencing a severe asthma exacerbation, which of the following medication orders would the progressive care nurse question?
A. Albuterol via continuous nebulization
B. Salmeterol 1 puff x 1 now
C. Magnesium sulfate 2 gm IVPB x 1
D. Prednisone 40 mg PO Q12 hr
Answer: B. Salmeterol 1 puff x 1 now
Treatment of the patient with a severe asthma exacerbation is focused on rapidly opening the airways and decreasing inflammation. Albuterol is a fast-acting beta-agonist that reverses bronchospasm by dilating the bronchioles to increase air flow. In severe exacerbations, nebulized albuterol can be administered on a continuous basis. Prednisone is a glucocorticoid used to open the airways by decreasing inflammation caused by asthma. IV magnesium sulfate acts as a bronchodilator and may be used in patients who experience severe exacerbations. Salmeterol is a long-acting beta-agonist prescribed for regular, routine use in patient with persistent asthma. Salmeterol-containing agents (e.g. Advair®) are CONTRAINDICATED in acute exacerbation because of their delayed time to onset.
A patient's insulin pump has just been restarted several days after surgery. The progressive care nurse focuses assessment of this patient on early detection of
B. pump site infiltration.
D. volume overload.
Answer: A. hypoglycemia.
Patients receiving continuous insulin infusions via pump or intravenous drip are at risk for hypoglycemia and require careful monitoring. The nurse should constantly be aware of signs and symptoms such as drowsiness, dizziness, diaphoresis, tachycardia, and personality changes. Patients resuming insulin pump use may resume their self-monitoring routine or have more frequent checks as needed. When a patient is receiving continuous intravenous insulin therapy, blood glucose monitoring should be performed at least every 2 hours, and more frequently when the drip is first initiated or when any changes in infusion rate are made. Insulin pump infusions are concentrated, run slowly, and are injected in the subcutaneous tissue, so site infiltration and fluid overload are not significant problems.
A patient with a history of esophageal varices returns to the progressive care unit following a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The nurse monitors the patient for signs of common complications by assessing for
A. unilaterally absent breath sounds.
B. dropping hemoglobin and hematocrit levels.
C. rising prothrombin time and PT-INR levels.
D. bleeding from the femoral puncture site.
Answer: B. dropping hemoglobin and hematocrit levels.
A TIPS procedure involves catheterization of the jugular vein in order to insert a shunt through the vena cava, into the liver. The shunt--placed between the portal and hepatic veins--is designed to improve blood flow and decrease portal vein pressure. This procedure is appropriate for patients with recurrent variceal bleeding and for those who have failed attempts at endoscopic hemorrhage control. Postprocedural bleeding is related to hepatic vessel injury or variceal rebleeds. Dropping hemoglobin and hematocrit levels may be the first sign of blood loss. In the TIPS population, coagulation studies are frequently abnormal prior to the procedure, due to preexisting liver dysfunction. The presence of unilaterally absent breath sounds (pneumothorax) is an unlikely finding when a jugular (vs. subclavian) approach is used.
A patient with a history of ischemic stroke 2 years ago is a admitted to a progressive care unit with acute onset facial droop and slurred speech. In addition to documenting the patient's National Institute of Health Stroke Scale (NIHSS) score, which of the following is an assessment priority? Performing a
A. dysphagia screen.
B. detailed neurological exam.
C. grip equality assessment.
D. pronator drift test.
Answer: B. detailed neurological exam.
The NIHSS is a validated tool for assessing stroke symptoms and determining prognosis. This scale has become a standard of care for patients with stroke or transient ischemic attack (TIA). The NIHSS--a basic assessment of cognition, sensation, and motor function--generates a score that can be tracked over time to determine patient improvement or signs of further compromise. However, a detailed neurological exam must be performed in addition to the NIHSS to more comprehensively evaluate cranial nerve function and mental status. A patient admitted with facial droop and slurred speech automatically fails a nursing dysphagia screen and requires swallow evaluation by a licensed speech therapist. Grip equality testing is part of the detailed neurological exam, but it does not provide other necessary information.
Progressive Care Nursing Review PCCN
Progressive Care Nursing Review PCCN®
Pocket Study Guide Volume 3
Kyla F. Woodward MN RN CCRN PCCN
Laura M. Criddle PhD RN CCRN CCNS FAEN