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The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?
- A. Lay the patient flat
- B. Notify the family of the patients critical state
- C. Stay with the patient
- D. Update the physician
Correct Answer: C
Rationale: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.
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The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurses next appropriate action?
- A. Palpate the patients carotid pulse
- B. Illuminate the patients call light
- C. Begin performing chest compressions
- D. Activate the Emergency Response System (ERS)
Correct Answer: D
Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?
- A. Stroke
- B. Myocardial infarction (MI)
- C. Hemorrhage
- D. Peripheral edema
Correct Answer: A
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action?
- A. Rapidly assess the patients cardiopulmonary status
- B. Arrange for an ECG
- C. Increase the height of the patients bed
- D. Manage the patients anxiety
Correct Answer: A
Rationale: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.
Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?
- A. Pulmonary edema
- B. Pericardiocentesis
- C. Cardiac tamponade
- D. Pericarditis
Correct Answer: C
Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.
- A. Platelet level
- B. Fluid status
- C. Cardiac rhythm
- D. Action of medications
- E. Sputum volume
Correct Answer: B,C,D
Rationale: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.