client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

Heart rate 102 beats/min

Report of chest pain

Blood pressure 103/54 mm Hg

Pedal pulses 1+ bilaterally

Answer and Explanation

The Correct Answer is C

Among the given options, the assessment data that indicate the need for immediate action by the nurse is a blood pressure of 103/54 mm Hg. This blood pressure reading indicates hypotension, which can be concerning for a post-angioplasty patient.

Angioplasty with stent placement is an invasive procedure, and patients may experience fluctuations in blood pressure during the immediate post-operative period. Hypotension after angioplasty can be a sign of inadequate cardiac output, which may be due to issues like bleeding, fluid loss, or heart dysfunction. Inadequate blood pressure can lead to decreased perfusion to vital organs, including the heart itself, and can be life-threatening.

Options A, B, and D are also important to address:

A) Heart rate 102 beats/min: A heart rate of 102 beats per minute may indicate tachycardia, which can be expected after a procedure like angioplasty. However, it is not as urgent of a concern as hypotension, and it may be a normal compensatory response to the body's stress.

B) Report of chest pain: Chest pain after angioplasty can be common, but it should be evaluated further to ensure it is not indicative of complications such as coronary artery spasms, clot formation, or restenosis of the treated artery. While this is an important issue to address, it does not take precedence over hypotension.

D) Pedal pulses 1+ bilaterally: This finding suggests that the peripheral pulses in the feet are weak, and it could be related to the patient's medical condition, medications, or positioning. While it requires attention, it is not an immediate threat to the patient's life compared to severe hypotension.

Therefore, the nurse should prioritize assessing and addressing the low blood pressure to prevent further complications and ensure the patient's stability. The nurse should promptly notify the healthcare provider and implement appropriate interventions, such as administering intravenous fluids, to increase blood pressure to a safe level.

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Correct Answer is A

Explanation

In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.

The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.

While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory

distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.

A. Need to begin an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Importance of making an annual appointment with the health care provider D. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors

Correct Answer is D

Explanation

Discharge teaching for a client with heart failure and reduced ejection fraction should prioritize education about medications that are essential in managing heart failure, such as angiotensin-converting enzyme (ACE) inhibitors.

ACE inhibitors are a class of medications commonly prescribed to heart failure patients with reduced ejection fraction. They work by dilating blood vessels, reducing the workload on the heart, and improving the heart's pumping ability. They are one of the cornerstones of heart failure management and have been shown to reduce symptoms, improve quality of life, and prolong survival in heart failure patients.

Educating the client about the benefits and effects of ACE inhibitors is crucial to promote medication adherence and ensure they understand the importance of taking this medication as prescribed. Common side effects, such as dizziness or dry cough, should also be discussed so the client knows what to expect and when to notify their healthcare provider.

While the other options may also be relevant to a client with heart failure, including starting an aerobic exercise program (A), reducing salt intake (B), and scheduling regular follow-up appointments (C), the immediate priority in discharge teaching should be about the medication regimen and the specific benefits and effects of ACE inhibitors. Other aspects of heart failure management can be addressed during the overall education and follow-up sessions.

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client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Correct Answer is A

Explanation

Which topic will the nurse plan to include in discharge teaching for a client who has heart failure with reduced ejection fraction?

Correct Answer is D

Explanation

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

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