The nurse has just received change-of-shift report about these four patients.
Which patient should the nurse assess first?
A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI.
A 60-year-old who has a scheduled dose of atenolol (Tenormin) 25 mg PO due.
A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain.
A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge.
The Correct Answer is A
Choice A rationale
Post-procedure monitoring after a percutaneous coronary intervention (PCI) and coronary arteriogram is the highest priority due to the risk of acute complications. The nurse must assess for signs of arterial bleeding, hematoma formation at the insertion site, and distal neurovascular compromise. Additionally, there is a risk of acute stent thrombosis or coronary artery dissection, which requires immediate hemodynamic monitoring and physical assessment to ensure patient stability during the critical recovery period.
Choice B rationale
Administering a scheduled beta-blocker like atenolol is a routine task that does not take precedence over an unstable or high-risk post-operative patient. While beta-blockers are essential for managing myocardial oxygen demand and blood pressure (normal systolic 90-120 mmHg), a 60-year-old stable patient can wait briefly. The nurse should check the heart rate (normal 60-100 bpm) and blood pressure before administration, but this assessment is secondary to the immediate needs of a post-PCI patient.
Choice C rationale
Pericarditis often presents with sharp, stabbing chest pain that may worsen with inspiration or lying flat. While this pain is distressing to the 38-year-old patient, it is a characteristic and expected finding of the inflammatory process affecting the pericardium. In the absence of signs of cardiac tamponade, such as Jugular Venous Distension or muffled heart sounds, this patient is hemodynamically more stable than a patient who just returned from a PCI procedure.
Choice D rationale
Anxiety regarding discharge four days after a myocardial infarction is a psychosocial concern rather than a physiological emergency. While addressing the 45-year-old patient's fears and providing education are important components of nursing care, they do not require immediate intervention over a patient at risk for hemorrhage or acute cardiac ischemia. Psychosocial assessments should follow the stabilization of all patients with potential airway, breathing, or circulation issues on the medical-surgical unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Adenosine is the first-line pharmacological treatment for stable, symptomatic supraventricular tachycardia (SVT). It works by briefly slowing or completely blocking conduction through the atrioventricular (AV) node. This action can interrupt re-entry circuits and restore a normal sinus rhythm. Due to its extremely short half-life of less than 10 seconds, it must be administered as a rapid intravenous bolus followed by a quick saline flush to ensure the medication reaches the heart effectively.
Choice B rationale
Cardizem, also known as diltiazem, is a calcium channel blocker used primarily for rate control in atrial fibrillation or atrial flutter. While it can be used for SVT if adenosine is ineffective, it is not typically the first drug of choice for the immediate conversion of an acute, sustained SVT. It works by inhibiting the influx of calcium ions during membrane depolarization of cardiac muscle, which slows the ventricular response but doesn't always terminate the arrhythmia.
Choice C rationale
Lidocaine is a Class IB antiarrhythmic primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or frequent premature ventricular contractions. It acts by suppressing the automaticity of the ventricular conduction system and increasing the electrical stimulation threshold of the ventricle. It has virtually no effect on the atrial tissue or the AV node, making it an inappropriate and ineffective choice for treating supraventricular tachycardia, which originates above the ventricles.
Choice D rationale
Atropine is an anticholinergic medication used to treat symptomatic bradycardia by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Administering atropine to a patient who already has a sustained tachycardia would be extremely detrimental, as it would further accelerate the heart rate and increase myocardial oxygen demand. Its mechanism of action is the exact opposite of what is required to treat a fast, supraventricular rhythm.
Correct Answer is C
Explanation
Choice A rationale
A decrease in ventricular response would indicate a worsening of the bradycardia or an increase in the degree of the heart block. Atropine is an anticholinergic medication that works by blocking vagal stimulation at the sinoatrial node, thereby increasing the firing rate. If the ventricular response decreased, the drug would have failed to counteract the parasympathetic influence, potentially leading to a further decline in cardiac output and worsening of the patient's symptomatic hypotension.
Choice B rationale
While an increase in peripheral pulse volume suggests improved stroke volume and systemic perfusion, it is a secondary effect of an improved heart rate and rhythm. Atropine's primary and direct mechanism of action is the acceleration of the cardiac rate. Pulse volume can be influenced by many factors, including vascular tone and fluid volume, making it a less specific indicator of atropine's direct pharmacological success compared to a measured increase in chronotropy.
Choice C rationale
Atropine is the first-line treatment for symptomatic bradycardia because it inhibits the muscarinic acetylcholine receptors. By blocking the parasympathetic nervous system's slowing effect on the heart, it increases the rate of SA node discharge and improves conduction through the AV node. An increase from the baseline heart rate of 30 towards a more normal range (60 to 100 beats per minute) directly demonstrates that the drug has reached its therapeutic target.
Choice D rationale
Premature contractions are ectopic beats arising from irritable foci in the atria or ventricles. Atropine is not indicated for the suppression of ectopy; in fact, by increasing the heart rate, it may sometimes increase myocardial oxygen demand and potentially exacerbate irritability in an ischemic heart. The primary goal in this clinical scenario is to resolve the profound bradycardia and hypotension resulting from the myocardial infarction, not to manage minor rhythm irregularities like PVCs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.