Nokea
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.
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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.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
- A. Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories
- B. Morphine sulphate, oxygen, and bed rest
- C. Oxygen and beta-adrenergic blockers
- D. Bed rest, albuterol nebulizer treatments, and oxygen
Correct Answer: B
Rationale: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action?
- A. Document the patients low urine output and monitor closely for the next several hours
- B. Contact the dietitian and suggest the need for increased oral fluid intake
- C. Contact the patients physician and suggest assessment of fluid balance and renal function
- D. Increase the infusion rate of the patients IV fluid to prompt an increase in renal function
Correct Answer: C
Rationale: Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?
- A. The patient experiences chest pain, palpitations, or dyspnea
- B. The patient experiences a noticeable increase in heart rate during activity
- C. The patients oxygen saturation level drops below 96%
- D. The patients respiratory rate exceeds 30 breaths/min
Correct Answer: A
Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education?
- A. Ill try to stay in bed for the first few days to allow myself to heal
- B. Ill make sure that I dont cross my legs when Im resting in bed
- C. Ill keep pillows under my knees to help my blood circulate better
- D. Ill put on those compression stockings if I get pain in my calves
Correct Answer: B
Rationale: To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.