Nokea
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?
- A. Heart rate 102 beats/min
- B. Pedal pulses 1+ bilaterally
- C. Report of severe chest pain
- D. Blood pressure 103/54 mm Hg
Correct Answer: C
Rationale: The correct answer is C. Severe chest pain in a patient with acute coronary syndrome post-angioplasty indicates a potential complication like stent thrombosis or re-occlusion. Immediate action is needed to assess and manage. A: Heart rate 102 bpm may be expected post-procedure. B: Pedal pulses 1+ bilaterally may indicate decreased perfusion but not an immediate threat. D: Blood pressure 103/54 mm Hg may be low but not an immediate concern unless symptomatic.
You may also like to solve these questions
The client is on hydrochlorothiazide and digoxin. What effect can the nurse expect?
- A. Hydrochlorothiazide increases digoxin levels.
- B. Hydrochlorothiazide decreases digoxin levels.
- C. Hydrochlorothiazide decreases potassium, increasing the risk of digoxin toxicity.
- D. Digoxin can increase the effectiveness of hydrochlorothiazide.
Correct Answer: C
Rationale: Step-by-step rationale:
1. Hydrochlorothiazide is a diuretic that can cause hypokalemia.
2. Digoxin toxicity is more likely with low potassium levels.
3. Therefore, hydrochlorothiazide decreasing potassium levels can increase the risk of digoxin toxicity.
Summary:
A: Incorrect. Hydrochlorothiazide does not increase digoxin levels.
B: Incorrect. Hydrochlorothiazide does not decrease digoxin levels.
C: Correct. Hydrochlorothiazide can decrease potassium, increasing digoxin toxicity risk.
D: Incorrect. Digoxin does not increase the effectiveness of hydrochlorothiazide.
The nurse explains to the patient who is to undergo a coronary artery bypass graft that the procedure most often involves
- A. Using a synthetic graft as a tube for blood flow from the aorta to a coronary artery distal to an obstruction
- B. Resecting a stenosed coronary artery and inserting a synthetic arterial tube graft to replace the diseased artery
- C. Loosening the internal mammary artery from the chest wall and attaching it to a coronary artery distal to a stenosis
- D. Anastomosing reversed segments of a saphenous vein from the aorta to the coronary artery distal to an obstruction
Correct Answer: C
Rationale: The most common method of coronary artery bypass involves leaving the internal mammary artery attached to its origin from the subclavian artery but dissecting it from the chest wall and anastomosing it distal to an obstruction in a coronary artery.
A client complains of crushing chest pain that radiates to his left arm. He should be presented with the following treatment:
- A. Aspirin, oxygen, nitroglycerin, and morphine
- B. Aspirin, oxygen, nitroglycerin, and codeine
- C. Oxygen, nitroglycerin, meperidine, and thrombolytics
- D. Aspirin, oxygen, nitroprusside, and morphine
Correct Answer: A
Rationale: The correct answer is A: Aspirin, oxygen, nitroglycerin, and morphine.
1. Aspirin helps to inhibit platelet aggregation.
2. Oxygen aids in improving oxygenation.
3. Nitroglycerin dilates coronary arteries, reducing cardiac workload.
4. Morphine helps in relieving pain and reducing anxiety.
Summary:
- Choice B: Codeine is not indicated for acute coronary syndrome.
- Choice C: Meperidine is not recommended due to its adverse effects.
- Choice D: Nitroprusside is not typically used in the initial treatment of acute coronary syndrome.
The client is on a cardio-selective beta blocker. Why might this be ordered?
- A. The client cannot have blockage to the beta receptors in the blood vessels.
- B. The client needs a cardio-selective drug because of hypotension in non-cardio-selective beta blockers.
- C. The client has asthma that would be exacerbated by a non- cardio-selective beta blocker.
- D. The client has hypoglycemia that would be worsened with a non-cardio-selective beta blocker.
Correct Answer: C
Rationale: The correct answer is C because a client with asthma would be at risk of bronchoconstriction if given a non-cardio-selective beta blocker. Cardio-selective beta blockers primarily target beta-1 receptors in the heart, sparing beta-2 receptors in the lungs. This reduces the risk of bronchoconstriction in clients with asthma. Choices A, B, and D are incorrect because they do not address the specific concern of bronchoconstriction in clients with asthma. Answer A refers to blood vessel blockage, which is not the primary concern in this scenario. Answer B mentions hypotension, which is not directly related to the risk of bronchoconstriction in asthma. Answer D discusses hypoglycemia, which is not a primary concern with beta blockers in asthma management.
Which type of cuff does the nurse choose to ensure an accurate assessment?
- A. Cuff width appropriate for continuous bedside monitoring
- B. Cuff width suitable for assessing BP during position changes
- C. Cuff width appropriate for the diameter of the client's arm
- D. Cuff width greater than the diameter of the client's right arm
Correct Answer: C
Rationale: The correct cuff size ensures accurate blood pressure readings by matching the cuff width to the arm's diameter.