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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.
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The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response?
- A. Explore the factors underlying the patients anxiety
- B. Teach the patient guided imagery techniques
- C. Obtain an order for a PRN benzodiazepine
- D. Describe the procedure in greater detail
Correct Answer: A
Rationale: An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the patients anxiety before providing interventions such as education or medications.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
- A. Brachial artery
- B. Brachial vein
- C. Femoral artery
- D. Greater saphenous vein
Correct Answer: D
Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
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.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
- A. Nervousness or paresthesia
- B. Throbbing headache or dizziness
- C. Drowsiness or blurred vision
- D. Tinnitus or diplopia
Correct Answer: B
Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
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.