Nokea
The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurses most appropriate response?
- A. Administer sublingual nitroglycerin to allow the patient to finish the test
- B. Initiate cardiopulmonary resuscitation
- C. Administer analgesia and slow the test
- D. Stop the test and monitor the patient closely
Correct Answer: D
Rationale: Signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident.
You may also like to solve these questions
A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the patients cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate?
- A. Left-sided heart catheterization
- B. Cardiac telemetry
- C. Transesophageal echocardiography
- D. Hardwire continuous ECG monitoring
Correct Answer: D
Rationale: Two types of continuous ECG monitoring techniques are used in health care settings: hardwire cardiac monitoring, found in EDs, critical care units, and progressive care units; and telemetry, found in general nursing care units or outpatient cardiac rehabilitation programs. Cardiac catheterization and transesophageal echocardiography would not be used in emergent situations to monitor cardiac function.
During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI?
- A. Left midclavicular line of the chest at the level of the nipple
- B. Left midclavicular line of the chest at the fifth intercostal space
- C. Midline between the xiphoid process and the left nipple
- D. Two to three centimeters to the left of the sternum
Correct Answer: B
Rationale: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.
A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill patients?
- A. Pulmonary artery systolic pressure
- B. Right ventricular afterload
- C. Pulmonary artery pressure
- D. Left ventricular preload
Correct Answer: D
Rationale: Monitoring of the pulmonary artery diastolic and pulmonary artery wedge pressures is particularly important in critically ill patients because it is used to evaluate left ventricular filling pressures (i.e., left ventricular preload). This device does not directly measure the other listed aspects of cardiac function.
A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?
- A. Fluctuations in core body temperature
- B. Signs and symptoms of esophageal varices
- C. Signs and symptoms of compartment syndrome
- D. Perfusion distal to the insertion site
Correct Answer: D
Rationale: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.
The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what?
- A. Development of an atrial-septal defect
- B. Myocardial ischemia
- C. Formation of a pulmonary embolism
- D. Release of potassium ions from cardiac cells
Correct Answer: B
Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.