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The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action?
- A. Have the patient sit down and put his head between his knees
- B. Have the patient perform pursed-lip breathing
- C. Have the patient stand still and bend over at the waist
- D. Place the patient on bed rest in a semi-Fowlers position
Correct Answer: D
Rationale: When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowlers position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. No need to have the patient put his head between his legs because cerebral perfusion is not lacking.
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The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan?
- A. Facilitate daily arterial blood gas (ABG) sampling
- B. Administer supplementary oxygen, as needed
- C. Have patient maintain supine positioning when in bed
- D. Perform chest physiotherapy, as indicated
Correct Answer: B
Rationale: Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
- A. The symptoms indicate angina and should be treated as such
- B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology
- C. The symptoms indicate an acute coronary episode and should be treated as such
- D. Treatment should be determined pending the results of an exercise stress test
Correct Answer: C
Rationale: Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patients symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject?
- A. Symptoms of hypovolemia
- B. Symptoms of low blood pressure
- C. Complications requiring graft removal
- D. Intubation and mechanical ventilation
Correct Answer: D
Rationale: Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important that patients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most patients. Teaching would also generally not include rare complications that would require graft removal.
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified?
- A. Gender, obesity, family history, and smoking
- B. Inactivity, stress, gender, and smoking
- C. Obesity, inactivity, diet, and smoking
- D. Stress, family history, and obesity
Correct Answer: C
Rationale: The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.
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.