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A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment?
- A. Prompt initiation of an ECG
- B. Auscultation of the patients point of maximal impulse (PMI)
- C. Rapid assessment of the patients peripheral pulses
- D. Palpation of the patients cardiac apex
Correct Answer: A
Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.
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The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI, what will have happened to the myocardium?
- A. It may have developed an increased area of infarction during the time without treatment
- B. It will probably not have more damage than if he came in immediately
- C. It may be responsive to restoration of the area of dead cells with proper treatment
- D. It has been irreparably damaged, so immediate treatment is no longer necessary
Correct Answer: A
Rationale: When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
- A. Increase in the size of the arterys lumen
- B. Decrease in arterial blood flow in relation to venous flow
- C. Increase in the patients resting heart rate
- D. Increase in the patients level of consciousness (LOC)
Correct Answer: A
Rationale: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patients LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
- A. Nervousness or paresthesia
- B. Throbbing headache or dizziness
- C. Drowsiness or blurred vision
- D. Tinnitus or diplopia
Correct Answer: B
Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?
- A. He will remain on bed rest for 48 to 72 hours after the procedure
- B. He will be given vitamin K infusions to prevent bleeding following PCI
- C. A sheath will be placed over the insertion site after the procedure is finished
- D. The procedure will likely be repeated in 6 to 8 weeks to ensure success
Correct Answer: C
Rationale: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are administered during PCI.
The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following?
- A. Drug therapy and smoking cessation
- B. Diet and drug therapy
- C. Diet therapy only
- D. Diet therapy and smoking cessation
Correct Answer: D
Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.