NUR 242 Exam 4 Questions and Correct
Answers, With Complete Solution. Updated
2024/2025.
Normal BP
Systolic <120 / Diastolic <80
Pre-HTN
Systolic =120-139 / Diastolic=80-89
Stage 1 HTN
Systolic=140-159 / Diastolic=90-99
Stage 2 HTN
Systolic=>160 / Diastolic=>100
Malignant HTN
Extremely high BP >180/110
S/S of Malignant HTN
initially asymptomatic, headache upon awakening, blurred vision, dizziness, chest pain,
difficult breathing, numbness in face and legs, tinnitus, flushed face, epistaxis
HTN Crisis
acute and life threatening; accelerated HTN requires ER treatment because organ
damage can occur quickly
Pharmacological interventions for HTN
ACE Inhibitors, Diuretics, Calcium Channel Blockers, ARBs, and Beta Blockers
What symptom should you report right away with ACE Inhibitors?
Dry nagging cough- discontinue immediately and teach about orthostatic HTN in elderly
What is an example of an ACE inhibitor drug?
Lisinopril, Enalapril
What is an example of a Calcium Channel Blocker?
Verapamil, Amlodopine
What is an example of an ARB?
Losartan, Valsartan
What is an example of a Beta Blocker?
Metoprolol, Atenolol
Pt. teaching for Raynauds disease
Stop smoking, avoid cold and stress, wear warm clothing, take vasodilators as
prescribed
Pt. teaching for Burgers Disease
Use vasodilators as prescribed, smoking cessation, avoid injury to upper and lower
extremities, can cause gangrene
S/S of Peripheral Arterial Disease (PAD)
Leg pain, burning, cramping muscle discomfort when walking that stops at rest. As the
disease persists the pt can walk shorter distances
Post-OP Care for Femoral Artery Bypass graft?
, warmth, redness and edema are expected. Monitor for possible occlusion and
continuous aching pain (first sign of occlusion) Throbbing pain is due to increased blood
flow to the area.
Notify the physician immediately if they experience what S/S after a femoral artery
graft?
Cold, pale, cyanotic skin or decreased pulse
Amputation complications:
infection, phantom limb pain, flexion contractions
Amputation Post-OP care:
-DO NOT elevate limb on pillow (can cause flexion contractures)
-1st 24 hours elevate the foot of the bed to decrease edema then keep the bed flat
-24-48 hours- place the pt. in prone position to stretch muscles and prevent hip flexion
contractures
Pt with a DVT is at high risk for?
PE
DVT S/S
-calf/groin tenderness
-sudden unilateral swelling
-positive Homans sign
DVT Risk Factors
-venous stasis from varicose veins
-heart failure
-immobility
-use of birth control
-ulcerative colitis
-prolonged bedrest
DVT interventions:
-SCDs
-Compression hose
-Elevate extremities
-IV continuous Heparin
When a pt. is on IV continuous Heparin, what lab values do you monitor?
aPTT Values
What is the normal aPTT range?
30-40 seconds
1.5-3 times normal control levels
Call the MD if >70 seconds
Normal PT level:
11-12.5 seconds
-1.5-2.5 times normal control level when on Coumadin
Normal PTT level:
60-70 seconds
-1.5-2.5 times the normal control on Heparin
Normal INR level:
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