Nokea
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action?
- A. Document the patients low urine output and monitor closely for the next several hours
- B. Contact the dietitian and suggest the need for increased oral fluid intake
- C. Contact the patients physician and suggest assessment of fluid balance and renal function
- D. Increase the infusion rate of the patients IV fluid to prompt an increase in renal function
Correct Answer: C
Rationale: Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
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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.
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.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
- A. Begin ECG monitoring
- B. Obtain information about family history of heart disease
- C. Auscultate lung fields
- D. Determine if the patient smokes
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. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
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.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
- A. Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories
- B. Morphine sulphate, oxygen, and bed rest
- C. Oxygen and beta-adrenergic blockers
- D. Bed rest, albuterol nebulizer treatments, and oxygen
Correct Answer: B
Rationale: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.