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A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patients daily medication administration record, the nurse should anticipate administering what drug?
- A. Ibuprofen
- B. Clopidogrel
- C. Dipyridamole
- D. Acetaminophen
Correct Answer: B
Rationale: Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.
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The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
- A. P wave inversion
- B. T wave inversion
- C. Q wave changes with no change in ST or T wave
- D. P wave enlargement
Correct Answer: B
Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurses most appropriate action?
- A. Call for assistance and initiate cardiopulmonary resuscitation
- B. Reposition the patients leg in a nondependent position
- C. Promptly remove the femoral sheath
- D. Call for help and apply pressure to the access site
Correct Answer: D
Rationale: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
- A. Ineffective breathing pattern related to decreased cardiac output
- B. Anxiety related to fear of death
- C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
- D. Impaired skin integrity related to CAD
Correct Answer: C
Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
- A. Brachial artery
- B. Brachial vein
- C. Femoral artery
- D. Greater saphenous vein
Correct Answer: D
Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patients psychosocial needs?
- A. Reinforce the fact that treatment will be successful
- B. Facilitate a referral to a chaplain or spiritual leader
- C. Increase the patients participation in rehabilitation activities
- D. Directly address the patients anxieties and fears
Correct Answer: D
Rationale: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the patients psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some patients, but it may exacerbate it for others.