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Chapter 38 Care of Patients with Acute Coronary Syndromes
Terms in this set (92)
The nurse is interviewing a patient reporting chest discomfort that occurs with moderate to prolonged exertion. The patient describes the pain as being "about the same over the past several months and going away with nitroglycerin or rest." Based on the patient's description of symptoms, what does the nurse suspect in this patient? (SATA)
a. Chronic stable angina (CSA)
b. Unstable angina
c. Acute coronary syndrome (ACS)
d. Acute myocardial infarction (MI)
e. Coronary artery disease (CAD)
A patient with a history of angina is admitted for surgery. The patient reports nausea, pressure in the chest radiating to the left arm, appears anxious, skin is cool and clammy, blood pressure is 150/90 mm Hg, pulse 100, and respiratory rate is 32. What are the priorities of nursing care for this patient? (SATA)
a. Relieve nausea
b. Maintain NPO status
c. Improve coronary perfusion
d. Improve coronary oxygenation
e. Relieve chest pain
A patient has been admitted for acute angina. Which diagnostic test identifies if the patient will benefit from further invasive management after acute angina or an MI?
a. Exercise tolerance test
b. Cardiac catheterization
c. Thallium scan
d. Multigated angiogram (MUGA) scan
The nurse is talking to a patient with angina about resuming sexual activity. Which statement by the patient indicates a correct understanding about the effects of angina on sexual activity?
A. "I won't be able to resume the same level of physical exertion as I did before I had chest pain."
B. "I will discuss alternative methods with my partner since I will no longer be able to have sexual intercourse."
C. "If I cannot walk a mile, I am not strong enough to resume intercourse
d. "With approval from my health care provider, I should resume sexual activity in the mornings or after a rest period."
A patient with angina is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? (SATA)
a. "If one tablet does not relieve the angina after 5 minutes, take two pills."
B. "You can tell the pills are active when your tongue feels a tingling sensation."
C. "Keep your nitroglycerin with you at all times."
D. "The prescription should last about 6 months before a refill is necessary."
E. "If pain doesn't go away, just wait; the medication will eventually take effect."
F. "The medication can cause a temporary headache."
A patient reports chest pain that is unrelieved with a sublingual nitroglycerin tablet. What does the nurse administer next to this patient?
A. Valium intramuscularly
b. Morphine sulfate IV
c. Supplemental oxygen
d. Chewable aspirin
A patient is hypertensive and continues to have angina despite therapy with beta blockers. The nurse anticipates which type of drug will be prescribed for this patient?
A. Calcium channel blocker
c. ACE inhibitor
The nurse has just given a patient two doses of sublingual nitroglycerin for angina pain. The patient's blood pressure is typically 130/80 mm Hg. Which finding warrants immediate notification of the health care provider?
A. Patient reports a headache
b. Systolic pressure is 140 mm Hg.
C. Systolic pressure is 90 mm Hg.
D. Anginal pain continues but is somewhat relieved
A patient is admitted for unstable angina. The patient is currently asymptomatic and all vital signs are stable. Which position does the nurse place the patient in?
a. Any position of comfort
c. Sitting in a chair
Which are characteristics of angina? (SATA)
a. Pain is precipitated by exertion or stress
b. Pain occurs without cause, usually in the morning
c. Pain is relieved only by opioids
d. Pain is relieved by nitroglycerin or rest
e. Nausea, diaphoresis, feelings of fear, and dyspnea may occur
f. Pain lasts less than 15 minutes
Which statement about CAD is accurate?
A. Ischemia that occurs with angina lasts more than 30 minutes and does not cause permanent damage of myocardial tissue.
B. Postmenopausal women in their 70s have the same incidence of MI as men
c. Many patients suffering sudden cardiac arrest die before reaching the hospital due to atrial fibrillation
d. Studies have shown that CAD in women manifests with the same symptoms as with men
A patient is admitted for acute MI, but the nurse notes that the traditional manifestation of a STEMI is not occurring. What other evidence for acute MI does the nurse expect to find in the patient? (SATA)
a. Positive troponin markers
b. Chronic stable angina
c. non-STEMI on ECG
d. Cardiac dysrhythmia e. Heart failure
People should seek treatment for symptoms of MI rather than delay because physical changes will occur approximately how many hours after an infarction?
A. 3 hours
b. 6 hours
c. 12 hours
d 24 hours
The nurse is caring for a patient admitted with unstable angina and elevated lipid levels. What does the nurse include in teaching this patient about his or her elevated lipid levels? (SATA)
a. Begin a vigorous exercise program
b. Avoid trans-fatty acids
c. Reduce intake of saturated fats
d. Monitor the amount of cholesterol ingested, staying below 200 mg/day
e Consider a weight loss program
The nurse is auscultating the heart of a patient who had an MI. Which finding most strongly indicates heart failure?
b. S3 gallop
c. Spilt S1 and S2
d. Pericardial friction rub
The nurse administers sublingual nitroglycerine to a patient experiencing an angina episode. How soon does the nurse expect the pain to begin to subside?
A. 1-2 minutes
b. 5-6 minutes
c 10-12 minutes
d 15-20 minutes
Which diagnostic tests are used to assess myocardial damage caused by an MI? (SATA)
a. Positive chest x-ray
b. Creatine kinase (CK) elevation
c. ECG: ST depression
d. CK-MB isoenzymes elevation
e. Troponin I isoenzyme elevation
A patient has heart failure related to MI. What intervention does the nurse plan for this patient's care?
A. Administering digoxin (Lanoxin) 1.0 mg as a loading dose and then daily
b. Infusing IV fluids to maintain a urinary output of 60 mL/hr
c. Titrating vasoactive drugs to maintain a sufficient cardiac output
d. Observing for such complications as hypertension and flushed, hot skin
Which patient has the highest risk for death because of ventricular failure and dysrhythmias related to damage to the left ventricle?
A. Patient with an anterior wall MI
b. Patient with a posterior wall MI
c. Patient with a lateral wall MI
d. Patient with an inferior wall MI
A patient had an MI. The nurse closely monitors the patient for which dysrhythmia associated with inferior wall MI?
a. Bradycardia and second-degree heart block
b. Premature ventricular contractions
c. Supraventricular tachycardia
d. Atrial fibrillation
The nurse is giving a community presentation about heart disease. Because many sudden cardiac arrest victims die of ventricular fibrillation before reaching the hospital, which teaching point does the nurse emphasize?
A. Controlling alcohol consumption and quitting cigarette smoking
b. Modifying risk factors such as diet and weight, and blood pressure medication compliance
c. Recognizing the difference between chronic stable angina and unstable angina
d. Learning to operate the automatic external defibrillators (AEDs) in the workplace
Metabolic syndrome increases the risk for coronary heart disease. Which are indicators of this syndrome? (SATA)
a. Triglyceride level of 170 mg/dL
b. HDL cholesterol level of 45 mg/dL in a male
c. HDL cholesterol level of 45 mg/dL in a female
d. Blood pressure of 10/86 mm Hg while taking a beta blocker
e. Fasting blood sugar level of 120 mg/dL
Which are early reaction is most common in patients with the chest discomfort associated with unstable angina or MI?
A patient is trying to make dietary modifications to reduce lipid levels. The patient would like information about omega-3 fatty acid food sources. What best source does the nurse recommend?
b. Flaxseed oil
A patient comes to the walk-in clinic reporting left anterior chest discomfort with mild shortness of breath. The patient is alert, oriented, diaphoretic, and anxious. What is the priority action for the nurse?
a. Obtain a complete cardiac history to include a full description of the presenting symptoms
b. Place the patient in Fowler's position and start supplemental oxygen
c. Instruct the patient to go immediately to the closet full-service hospital
d. Immediately alter the physician and establish IV access
A patient reports having chest discomfort that started during exercise. The patient is currently pain-free, but is "concerned." What questions must the nurse ask to assess the patient's pain episode? (SATA)
a. "When did the pain start and how long did it last?"
b. "What were you doing when the pain started?"
c. "What did you do to alleviate the pain?"
d. "How did you feel about the pain?"
e. "Did the pain radiate to other locations?"
f. "On a scale of 0 to 10 with 10 as the worst pain, what number would you use to categorize the pain?"
A patient is currently pain- and symptom-free, but reports having intermittent episodes of chest pain over the past week. The nurse asks about which associated symptoms? (SATA)
e. Joint pain
f. Shortness of breath
The ED nurse is assessing an 86-year-old patient with acute confusion, increased respiratory rate, anxiety, and chest pain. The nurse finds a respiratory rate of 36/min with crackles and wheezes on auscultation. How does the nurse interpret these findings?
A. Left ventricular heart failure
b. Atypical angina
d. unstable angina
The nurse is assessing a middle-aged woman with diabetes who denies any history of known heart problems. However, on auscultation of the heart the nurse hears an S4 heart sound. The nurse alerts the physician and obtains an order for which diagnostic test?
A. Blood glucose level
c. Chest x-ray
A middle-aged patient with no known medical problems has acute-onset chest pain and dyspnea. In order to rule out acute MI, the nurse obtains orders for which diagnostic test? (SATA)
a. Triglyceride levels and C-reactive protein
b. Chest x-ray
c. Total serum cholesterol, low-density lipoprotein, high-density lipoprotein
d. Troponin T and I e. Creatine kinase-MB f. ABGs
A patient had severe chest pain several hours ago but is currently pain-free and has a normal ECG> Which statement by the patient indicates a correct understanding of the significance of the ECG results?
A. "I'll go home and make an appointment to see my family doctor next week."
B. "The ECG could be normal since I am currently pain-free."
C. "A normal ECG means I am okay"
d. "I have always had a strong heart, low blood pressure, and a normal ECG."
Which statement about silent MI is correct?
A. In a silent MI, the patient does not have any pain, so there is less myocardial damage.
B. Diabetic patients are prone to silent MI that goes undiagnosed without complications
c. Silent MI increases the incidence of new coronary events
d. In silent MI, the myocardium is oxygenated by increased collateral circulation
The ED nurse is caring for a patient with acute pain associated with MI. What are the purposes of collaborative management that address the patients pain? (SATA)
a. Return the vital signs and cardiac rhythm to baseline, so the patient can resume activities of daily living.
B. Prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply
c. Aggressively diagnose and treat life-threatening cardiac dysrhythmias and restore pulmonary wedge pressure
d. Closely monitor the patient for accompanying symptoms such as nausea and vomiting or indigestion
e. Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply
The ED nurse, caring for a patient with severe chest pain and ECG changes, gives supplemental oxygen to the patient as ordered. Which other medications does the nurse anticipate giving to this patient? (SATA)
a. IV nitroglycerin
b. Beta blocker
c. IV morphine
d. Oral aspirin
e. ACE inhibitor
The nurse is caring for a hospitalized patient being treated initially with IV nitroglycerin. What intervention must the nurse include in this patient's care?
A. Increase the dose rapidly to achieve pain relief
b. Restrict the patient to bedrest with bedpan use
c. Monitor blood pressure continuously
d. Elevate the head of the bed to 90 degrees
During an annual physical exam, a patient receives an ECG and has an abnormal Q wave in several leads. What is the nurse's best interpretation of this result?
A. The patient is experiencing a silent MI
b. The patient has experienced an MI in the past
c. The patient is having an acute MI at the moment
d. The patient is experiencing ischemia at the moment
The home health nurse receives a call from a patient with CAD who reports having new onset of chest pain and shortness of breath. What does the nurse instruct the patient to do?
A. Rest quietly until the nurse can arrive at the house to check the patient
b. Chew 325 mg of aspirin and immediately call 911
c. Use supplemental home oxygen until symptoms resolve
d. Take three nitroglycerin tablets and have family drive the patient to the hospital
A patient is newly diagnosed with cardiovascular disease. What psychosocial reactions does the nurse assess for? (SATA)
Which drug is given within 1 to 2 hours of an MI when the patient is hemodynamically stable, to help the heart to perform more work without ischemia?
A. Vasodilators, such as sublingual or spray nitroglycerin (NTG)
b. Beta-adrenergic blocking agents, such as metoprolol (Lopressor)
c. Antiplatelet agents, such as clopidogrel (Plavix)
d. Calcium channel blockers, such as diltiazem (Cardizem)
Which statements are true about the use of thrombolytic agents for a patient with an acute MI? (SATA)
a. A patient who has received a thrombolytic agent must be continuously monitored before and after the medication is given
b. Thrombolytic therapy is indicated for chest pain of longer than 30 minutes duration that is unrelieved by other medications.
C. There are no contraindications to thrombolytic therapy if the patient is having an acute MI as evidenced by cardiac enzymes and ECG.
D. Bleeding is a risk for patients receiving thrombolytic therapy
e. The nurse need only monitor clotting studies of the patient who has receive thrombolytic therapy. No further assessment is needed
The health care provider is considering use of thrombolytic therapy for a patient. What is the criterion for this therapy?
A. Chest pain of greater than 15 minutes duration that is unrelieved by nitroglycerin
b. Indications of transmural ischemia and injury as shown by the Ecg
c. Ventricular dysrhythmias shown on the cardiac monitor
d. History of chronic, severe, poorly controlled hypertension
A patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure? (SATA)
a. Ischemic stroke within 3 months
c. Suspected aortic aneurysm
d. Major trauma in the last 12 months
e. Intracranial hemorrhage
f. Malignant intracranial neoplasm
The health care provider is considering treating a 125-pound 76-year-old MI patient with thrombolytic therapy. What action does the nurse expect regarding this therapy for this patient?
A. Due to her age, the patient will not receive this therapy
b. The thrombolytic therapy dosage may be decreased to decrease risk of bleeding
c. Heparin by continuous IV is the best choice after antiplatelet therapy with an aspirin
d. Because the MI is recent, the patient will receive the usual dosage of thrombolytic drug
A patient has received thrombolytic therapy for treatment of acute MI. What are postadministration nursing responsibilities for this treatment? (SATA)
a. Document the patient's neurologic status
b. Observe all IV sites for bleeding and patency
c. Monitor WBC count and differential
d. Monitor clotting studies
e. Monitor hemoglobin and hematocrit
f Test stools, urine, and emesis for occult blood
A patient is receiving beta-blocker therapy for treatment of MI. What does the nurse monitor for in relation to this therapy? (SATA)
c. Decreased level of consciousness
d. Chest discomfort
e. Increased urinary output
A patient is being treated with medication therapy following an acute MI. The nurse questions the order for which type of drug?
A. Calcium channel blocker
c. ACE inhibitor
A patient with angina is taking calcium channel blockers. For which complication does the nurse monitor with this patient?
Which diagnostic test is performed after angina or MI to determine cardiac changes that are consistent with ischemia, to evaluate medical interventions, and to determine whether invasive intervention is necessary?
A. Stress test
d. Chest x-ray
The nurse is monitoring a patient who received fibrinolytics and percutaneous coronary intervention (PCI). What is an indication that the clot has lysed and the artery reperfused?
A. Abrupt increase of pain or discomfort
b. Sudden onset of ventricular dysrhythmias
c. Appearance of ST-segment depression
d. Obvious T wave inversion
A patient has had an MI. The nurse anticipates which type of drug will be prescribed within 48 hours to prevent the development of heart failure?
A. Calcium channel blockers
b. Ace inhibitor
c. Beta blockers
The nurse has identified the priority problem of activity intolerance for a patient who had an acute MI> What is the best expected outcome for this patient?
A. Patient will walk at least 200 feet four times a day without chest discomfort or shortness of breath
b. Patient will name three or four activities that will not cause shortness of breath or chest pain
c. Nurse will teach the patient to exercise and to take the pulse if symptoms of shortness of breath or pain occur
d. Nurse will assist the patient with ADLs until shortness of breath or pain resolves
A patient is in the acute phase (phase 1) of cardiac rehabilitation. Which task is best to delegate to the UAP?
A. Assist the patient to ambulate approximately 200 feet three times a day.
B. Assist the patient with ambulation to the bathroom
c. Assess heart rate, blood pressure, respiratory rate, and fatigue with each higher level of activity
d. Assist the patient into the bath tub
A patient in the cardiac rehabilitation facility is having difficulty coping with the changes in her health status. Which statement by the patient is the strongest indicator of ineffective or harmful coping?
A. "I don't mind going to therapy, but I'm not sure if I'm getting any benefit from it."
B. "I'll take the pills and just do whatever you want me to do."
C. "I don't want to go to therapy; I had a bad experience yesterday with the therapist."
D. "I know I need to talk about going home soon, but could we discuss it later?"
A post-MI patient in phase q cardiac rehabilitation is encouraged to perform which activity?
A. Range-of-motion exercises
b. Modified weight training
c. Stair climbing
The nurse is caring for a patient admitted for an IWMI. The patient develops heart block with bradycardia. Because the patients pulse rate is low and the blood pressure is unstable, which procedure is the nurse prepared to assist with?
A. Temporary pacemaker
c. 16-lead ECG
d. Percutaneous intervention
The nurse is contacted by the cardiac monitoring technician who says a patient is having a dysrhythmia. What does the nurse do first?
A. Notify the Rapid Response Team
B. Administer antidysrhythmic medication
c. Evaluate the patient for chest pain or discomfit
d. Double-check the lead placement
The nurse is evaluating a patient with CAD. What is an expected patient outcome that demonstrates hemodynamic stability?
A. Blood pressure and pulse are within range and adequate for metabolic demands
b. Urine output increases from 15 to 30 mL per hour
c. P waves are regular and there are no abnormal heart sounds
d. Patient expresses verbal understanding of risk factors and need for compliance
The nurse is assessing a patient at risk for left ventricular failure and inadequate organ perfusion. Which signs and symptoms signal decreased cardiac output? (SATA)
a. Change in orientation or mental status
b. Urine output less than 1 mL/kg (2.2 lbs)/hr or less than 30 mL/hr
c. Hot, dry skin with flushed appearance
d. Cool, clammy extremities with decreased or absent pulses
e. Unusual fatigue
f. Recurrent chest pain
The nurse is reviewing medication orders for several cardiac patients. There is an order for beta-adrenergic blocking agent metoprolol SL (Toprol XR) once a day. This drug order is most appropriate for which class of patients, according to the Killip classification system?
A. All classes
b. Class I only
c. Class II and III
d. Class IV only
The nurse is caring for a patient with an AWMI. The patient develops tachycardia, hypotension, urine output of 10 mL/hr, cold and clammy skin with poor peripheral pulses, and agitation. What does the nurse suspect in this patient?
A. Ventricular dysrhythmia
b. Cardiogenic shock
c. Postpericardiotomy syndrome
d. Acute coronary syndrome
The nurse is assessing a cardiac patient and finds a paradoxical pulse, clear lungs, and jugular venous distention that occurs when the patient is in a semi-Fowlers position. What are these findings consistent with?
A. Right ventricle failure
b. Unstable angina
d. Valvular disease
The intensive care nurse is monitoring a patient with a right ventricular MI. The pulmonary artery wedge pressure (PAWP) reading is 30 mm Hg. What does the nurse do next?
A. Increase the IV fluid rate to 200 mL/hour
b. Auscultate the lungs to assess for left-sided heart failure
c. Perform an ECG suing right-sided precordial leads
d. Place the patient in semi-Fowlers position.
A patient continues to have chest pain despite compliance with medical therapy. The nurse teaches the patient about which diagnostic test?
A. Left-sided cardiac catheterization with coronary angiogram
b. Percutaneous transluminary coronary angioplasty (PTCA)
c. Coronary artery bypass grafting (CABG)
d. Stent placement in coronary artery
Immediate reperfusion is an invasive intervention that shows some promise for managing which disorder?
A. Right ventricular failure
b. Metabolic syndrome
c. Cardiogenic shock
d. Acute coronary syndrome
A patient is scheduled to have PCI. The nurse anticipates that an initial dose of which medication will be given before the procedure?
A. Clopidogrel (Plavix)
b. Nitroglycerin (Nitrostat)
c. Isosorbide mononitrate (Imdur)
d. Carvedilol (Coreg)
A patient has angina and is scheduled for PCI. Based on negative outcomes of the PCI, the nurse prepares the patient for immediate transfer to undergo which procedure?
A. Intraaortic balloon pump
c. Cardiac catheterization
d. Carotid endarterectomy
The nurse is caring for a patient who had PCI. Which symptom indicates acute closure of the vessel and therefore warrants immediate notification of the health care provider?
A. Chest pain
c. Bleeding at the insertion site
d. Cough and shortness of breath
Which patients may be potential candidates for CABG? (SATA)
a. Patient with angina and greater than 50% occlusion of left main coronary artery that cannot be stented
b. Patient with unstable angina with moderate vessel disease appropriate for stenting
c. Patient with Valvular disease
d. Patient with coronary vessels unsuitable for PTCA
e. Patient with acute MI responding to therapy
f. Patient with signs of ischemia or impending MI after angiography or PTCA
The ICU patient with left ventricular failure has not responded to drug therapy to improve tissue perfusion. What intervention does the nurse expect may be tried next?
A. CABG surgery
b. Percutaneous insertion of an intraaortic balloon pump
c. Intravenous infusion of a thrombolytic agent
d. Insertion of a pulmonary artery catheter
A patient is having an elective CABG with a minimally invasive surgical technique. What does the nurse include in the preoperative teaching?
A. Prevention of edema and scarring at the harvest site
b. Protection and splinting of the chest incision while coughing
c. Availability of analgesics fi needed, but probably unnecessary
d. Limitation of ambulation for several days after the procedure
A patient is having a CABG with the traditional surgical procedure. What does the nurse include in the preoperative teaching? (SATA)
a. Coughing will be avoided to keep stress off the sternal incision
b. There will be a sternal incision
c. Expect one, two, or three chest tubes
d. An indwelling urinary catheter will be placed
e. An endotracheal tube will prevent talking
The intensive care nurse is caring for a patient who has just had a CABG. The nurse notes that the patient has edema. In order to adjust fluid administration, the nurse collects which additional information and then consults the health care provider? (SATA)
a. Blood pressure
c. Skin turgor
d. Cardiac output
e. Blood loss
f. Urine output
A potassium bolus of 80 mEq mixed in 100 mL of Iv solution at a rate of 40 mEq/hr is ordered for a patient in the critical care unit. What does the nurse do next?
A. Contact the health care provider because the order exceeds the recommended amount
b. Give the infusion; the order exceeds the recommended amount, but is within acceptable standards of practice for critical care patients
c. Contact the health care provider because even though the dosage is acceptable, the rate is too fast
d. Consult with the pharmacist because even though the rate is acceptable, the mixture is too concentrated
The intensive care nurse is caring for a patient who has just had CABG surgery. The patient has a systolic blood pressure of 80 mm Hg. What is the primary concern related to this patient's hypotension?
A. It is associated with warm cardioplegia
b. It may result in the collapse of the graft
c. It will result in acute tubular necrosis
d. It is related to mechanical ventilation
Following CABG surgery, a patient t has a body temperature below 96.8o F (36o C). What measures should be used to rewarm the patient?
A. Infuse warm IV fluids
b. Do not rewarm; cold cardioplegia is protective
c. Place the patient in a warm fluid bath
d. Use lights or thermal blankets
The intensive care nurse is caring for a patient who has just had CABG surgery. What does the nurse do to assess for postoperative bleeding?
A. Measure mediastinal and pleural chest tube drainage at least hourly and report drainage amounts over 150 mL/hr to the surgeon
b. Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amounts over 50 mL.hr to the surgeon
c. Assess the dressing over the sternal site every 4 hours and reinforce the dressing with sterile gauze as needed.
D Assess the donor site every 4 hours and report serous drainage and increasing pain to the surgeon
Following CABG surgery, a patient in the ICU on a mechanical ventilatory suddenly decompensates. The health care provider makes a diagnosis of cardiac tamponade. The nurse prepares the patient for which emergency procedure?
A. Chest tube
The nurse is assessing a patient who had CABG surgery. Which finding is a permanent deficit that is associated with an intraoperative stroke?
A. Decreased level of consciousness that resolves when body temperature is normal
b. Arousal from anesthesia takes several hours
c. Inability to speak clearly and coherently immediately after surgery
d. Generalized seizure activity
A patient reports pain after CABG surgery. Which statement by the patient suggests that the pain is related to the sternotomy and not anginal in origin?
A. "The pain goes down my arm or sometimes into my jaw."
B. "My pain increases when I cough or take a deep breath"
c. "The nitroglycerin helped to relieve the pain."
D. "I feel nausea and shortness of breath when the pain occurs."
A patient with CABG surgery is transferred from the ICU to the intermediate care unit. Which activity does the nurse assist the patient with?
A. Ambulating 25 to 100 feet three times a day as tolerated
b. Turning the patient every 2 hours for the first 48 hours
c. Dangling and turning every 2 hours for at least 24 hours d. Coughing and deep-breathing three times a day
A patient had CABG surgery with the radial artery used as a graft. The nurse performs which assessment specific to this patient?
A. Check the blood pressure every hour on the unaffected arm or use the legs
b. Check the fingertips, hand, and arm for sensation and mobility every shift
c. Assess hand color, temperature, ulnar/radial pulses, and capillary refill every hour initially
d. Note edema, bleeding, and swelling at the donor site, which are expected
A patient with CABG surgery has been diagnosed with mediastinitis. What information does the nurse expect to find in the patient's assessment documentation? (SATA)
a. Fever continuing beyond the first 4 days after CABG
b. Bogginess of the sternum
c. Redness and drainage from suture sites
d. Decreased white blood cell count
e. Induration or swelling at the suture sites
f. Anginal-type chest pain
A patient had CABG surgery with a vein graft. To help prevent collapse of the graft, what assessment does the nurse perform?
A. Auscultate lung sounds
b. Monitor for hypotension
c. Assess for motion and sensation
d. Observe for generalized hypothermia
The nurse is caring for a patient who had CABG surgery. The nurse pays close attention to which electrolyte levels for this postoperative patient? (SATA)
After a CABG surgery, a postoperative patient suddenly has a decrease in mediastinal drainage, jugular vein distention with clear lung sounds, pulsus paradoxus, and equalizing PAWP and right atrial pressure. What do these signs suggest to the nurse?
a. Acute MI
b. Occlusion at the donor site
c. Cardiac tamponade
d. Prinzmetal's angina
The nurse coming on duty receives the change of shift report. Which patient must be assessed first by the nurse?
a. Patient with anxiety, nausea, diaphoresis, and shortness of breath
b. Patient with diabetes mellitus and elevated serum lipid levels
c. Patient with a friction rub and elevated temperature
d. Patient with fever, instability of sternum, and increased white blood cell count
The nurse is caring for a patient who had a minimally invasive direct coronary artery bypass (MIDCAB). Which sign/symptom prompts the nurse to immediately contact the health care provider?
A. Acute incisional pain
b. ST-segment change in the V leads
c. Drainage form the chest tubes
d. Problems with coughing
A patient has discrete, proximal, noncalcified lesions of only one or two vessels. Which procedure is most likely to be recommended for this patient?
A. Percutaneous coronary intervention (PCI)
b. Stress test with pharmacologic agent
c. Immediate thrombolytic reperfusion therapy
d. Minimally invasive bypass surgery
The nurse is caring for patient who had a PCI. Which postoperative interventions are included in the care for this patient? (SATA)
a. Monitor for acute closure of the vessel
b. Observe for bleeding form the insertion site
c. Maintain bedrest for 48 hours
d. Observe for hypotension, hypokalemia, and dysrhythmias
e. Teach about medications such as aspirin and beta blockers or ACE inhibitors
f. Instruct about lifestyle changes relating to CAD
Treatment of hypothermia, a common problem after CABG surgery, is necessary because this condition may cause a patient to be at risk for which condition?
c. Heart failure
d. Loss of consciousness
Which statement is true about Postpericardiotomy syndrome?
A. It is a psychological disorder for which the patient needs emotional support
b. It is generally mild and self-limiting
c. It places the patient at high risk for cardiac tamponade
d. It can be prophylactically managed with antibiotics
The patient is scheduled to have robotic heart surgery. Which advantages of this type of surgery does the nurse teach the patient about? (SATA)
a. Shorter (2-3 day) hospital stay
b. Shorter surgical time than with traditional heart surgery
c. Less pain due to smaller incisions
d. Shorter time on heart-lung bypass machine
e. Chest tubes are never needed
What is MONA and what is it used for?
What is CRP and what is it indicative of
You are treating a patient involved in a motor vehicle collision while traveling at 65 miles per hour. The patient complains only of point tenderness in her neck. What kind of mechanism of injury has this patient sustained?
The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?
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