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The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.
- A. Abrupt closure of the coronary artery
- B. Venous insufficiency
- C. Bleeding at the insertion site
- D. Retroperitoneal bleeding
- E. Arterial occlusion
Correct Answer: A,C,D,E
Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.
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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 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.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
- A. Ineffective breathing pattern related to decreased cardiac output
- B. Anxiety related to fear of death
- C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
- D. Impaired skin integrity related to CAD
Correct Answer: C
Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.
A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment?
- A. Prompt initiation of an ECG
- B. Auscultation of the patients point of maximal impulse (PMI)
- C. Rapid assessment of the patients peripheral pulses
- D. Palpation of the patients cardiac apex
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. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.
The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
- A. Dyspnea
- B. Unusual fatigue
- C. Hypotension
- D. Syncope
- E. Peripheral cyanosis
Correct Answer: A,B,D
Rationale: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.