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The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response?
- A. Document this expected assessment finding during the initial postoperative period
- B. Reposition the patient with his left leg in a dependent position
- C. Inform the patients physician of this assessment finding
- D. Administer an ordered dose of subcutaneous heparin
Correct Answer: C
Rationale: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.
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A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient?
- A. Hyperlipidemia
- B. Bleeding at insertion site
- C. Left ventricular hypertrophy
- D. Congestive heart failure
Correct Answer: B
Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.
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 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.
The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments?
- A. Maximizing cardiac output while minimizing heart rate
- B. Decreasing energy expenditure of the myocardium
- C. Balancing myocardial oxygen supply with demand
- D. Increasing the size of the myocardial muscle
Correct Answer: C
Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with productivity.
The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?
- A. Coronary artery bypass graft (CABG)
- B. Percutaneous transluminal coronary angioplasty (PTCA)
- C. Atherectomy
- D. Cardiopulmonary bypass
Correct Answer: D
Rationale: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.