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Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which of the following actions should the nurse take next?
- A. Palpate the radial pulses bilaterally.
- B. Assess the feet for peripheral edema.
- C. Auscultate for a pericardial friction rub.
- D. Check the cardiac monitor for dysrhythmias.
Correct Answer: C
Rationale: The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.
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The nurse is assessing a patient who has chest pain is to the emergency department and all the following diagnostic tests are prescribed. Which of the following tests should the nurse arrange to be completed first?
- A. Electrocardiogram (ECG)
- B. Computed tomography (CT) scan
- C. Chest x-ray
- D. Troponin level
Correct Answer: A
Rationale: The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI).
Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, 'I don't understand how to care for myself' Based on this information, which of the following nursing diagnoses is appropriate?
- A. Ineffective health management related to insufficient knowledge
- B. Activity intolerance related to physical deconditioning
- C. Ineffective denial related to ineffective coping strategies
- D. Social isolation related to insufficient personal resources
Correct Answer: A
Rationale: The patient data indicate ineffective health management related to lack of knowledge of disease process, and care after discharge. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation.
The nurse is evaluating the outcomes of pre-operative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery. Which of the following patient statements indicates that additional teaching is needed?
- A. I will have incisions in my leg where they will remove the vein.
- B. They will circulate my blood with a machine during the surgery.
- C. I will need to take an Aspirin a day after the surgery to keep the graft open.
- D. They will use an artery near my heart to bypass the area that is obstructed.
Correct Answer: A
Rationale: When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.
The nurse is administering a fibrinolytic agent to a patient with an acute myocardial infarction. Which of the following assessments should cause the nurse to stop the drug infusion?
- A. Bleeding from the gums
- B. Surface bleeding from the IV site
- C. A decrease in level of consciousness
- D. A non-sustained episode of ventricular tachycardia
Correct Answer: C
Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected adverse effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A non-sustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.
The nurse is providing teaching to a patient about use of sublingual nitroglycerin. Which of the following patient statements indicates that the teaching has been effective?
- A. I will put the nitroglycerin tablet under my tongue if I get chest pain.
- B. I like fresh salmon and I will plan to eat it more often.
- C. I will miss being able to eat peanut butter sandwiches.
- D. I can have a cup of coffee with breakfast if I want one.
Correct Answer: A
Rationale: Sublingual nitroglycerin is taken by placing the tablet under the tongue to relieve chest pain. The other statements relate to dietary preferences and do not indicate understanding of nitroglycerin use.