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A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement on this client.
- A. Ensure the balloon does not remain wedged.
- B. Ensure the balloon does not remain wedged.
- C. Keep the client on strict NPO status.
- D. Maintain the client in a semi-Foolies position.
Correct Answer: B
Rationale: The balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.
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A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
- A. Client on a nitroglycerin infusion at 5 mcg/min, not titired in the last 4 hours.
- B. Client who is 1 day post coronary artery bypass graft with blood pressure 100/60 mm Hg.
- C. Client with a heart rate of 100 beats/min after angioplasty.
- D. Client with tongue swelling and anxiety post-angioplasty.
Correct Answer: D
Rationale: The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 100 beats/min has increased oxygen demands but is just over the normal limit for heart rate. The two post-coronary artery bypass clients are stable.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
- A. Allow the client to rest quality.
- B. Assess the client for bleeding.
- C. Document the findings in the chart.
- D. Medicate the client for pain.
Correct Answer: B
Rationale: A major complication related to intra-arterial blood pressure monitoring is hemorrhages from the insertion site. Since the vital signs are out of the normal range, are a chance, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest, the nurse first needs to assess for bleeding.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients 02 saturation to be low. What action by the nurse is most appropriate?
- A. Return the client to bed and apply oxygen.
- B. Continue to monitor the client's oxygen saturation.
- C. Notify the healthcare provider immediately.
- D. Encourage the client to take deep breaths.
Correct Answer: A
Rationale: Low oxygen saturation in a client post-myocardial infarction indicates potential hypoxemia, which can worsen cardiac ischemia. The nurse should return the client to bed and apply oxygen to improve oxygenation. Monitoring should continue, but immediate action is needed. Notifying the provider may be necessary if the situation does not improve, but oxygen administration is the priority. Encouraging deep breaths may help but is not sufficient alone.
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
- A. Assess the clients papillary responses.
- B. Request an neurologic consultation.
- C. Stop the infusion and call the provider.
- D. Take and document a full set of vital signs.
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.