The nurse is caring for a client after percutaneous coronary revascularization (PCR) via left groin site. Which assessments would the nurse obtain after the procedure? Select all that apply.

Monitor blood glucose

Neurovascular check of lower extremities

Check coagulation studies

Continuous ECG monitoring

Answer and Explanation

Correct Answer : B,C,D

a. Monitor blood glucose: Monitoring blood glucose levels may not be directly related to the procedure itself unless the client has a pre-existing condition such as diabetes mellitus. However, it is important to monitor for any changes in blood glucose levels post-procedure, especially if the client received medications such as intravenous dextrose during the procedure.

b. Neurovascular check of lower extremities: Assessing neurovascular status of the lower extremities is crucial after percutaneous coronary revascularization via the left groin site. This procedure involves accessing the femoral artery, which carries the risk of compromising blood flow to the lower extremity. Assessing for pulses, capillary refill, sensation, and motor function helps identify any potential complications such as bleeding, hematoma, or vascular compromise.

c. Check coagulation studies: Checking coagulation studies, such as activated partial thromboplastin time (aPTT) or prothrombin time (PT/INR), may be necessary after percutaneous coronary revascularization, especially if anticoagulant medications such as heparin were used during the procedure. Monitoring coagulation studies helps assess the client's risk of bleeding or thrombosis post-procedure.

d. Continuous ECG monitoring: Continuous electrocardiogram (ECG) monitoring is essential after percutaneous coronary revascularization to monitor for any changes in cardiac rhythm, ST-segment elevation or depression, and ischemic events. This helps identify any potential complications such as arrhythmias, myocardial infarction, or ischemia.

e. Verify contrast dye allergies: Verifying contrast dye allergies is important before performing any procedure involving the use of contrast media, such as percutaneous coronary revascularization. Allergic reactions to contrast dye can range from mild itching or rash to severe anaphylaxis. Identifying any allergies beforehand allows the healthcare team to take appropriate precautions and choose alternative imaging techniques if necessary.

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Correct Answer is D

Explanation

a. “The left side of your heart is having trouble overcoming the resistance in the blood vessels of your body.”

This explanation is not specific to mitral stenosis. It describes systemic vascular resistance, which is a broader concept related to hypertension and vascular health. Mitral stenosis specifically involves narrowing of the mitral valve, which affects blood flow between the left atrium and left ventricle.

b. “When your heart beats, some of the blood that should leave the left ventricle is backing up through a leaking valve.”

This explanation is more accurate for mitral regurgitation rather than mitral stenosis. Mitral regurgitation involves the leaking of blood backward through the mitral valve into the left atrium during ventricular systole. Mitral stenosis, on the other hand, involves narrowing or constriction of the mitral valve, which impedes the flow of blood from the left atrium to the left ventricle during diastole.

c. “The valve between your heart and lungs has become inelastic.”

This explanation is not entirely accurate. While mitral stenosis does involve changes in the mitral valve structure, such as thickening and calcification, the term "inelastic" does not fully describe the pathology of mitral stenosis. Mitral stenosis is characterized by the narrowing (stenosis) of the mitral valve orifice, which restricts blood flow from the left atrium to the left ventricle.

d. “The mitral valve has become stiff and narrowed which slows the blood between the two chambers.”

This explanation is the most accurate description of mitral stenosis. It correctly identifies the problem as the narrowing and stiffening (stenosis) of the mitral valve, which impedes the flow of blood from the left atrium to the left ventricle during diastole. This explanation helps the client understand how the condition affects the function of the mitral valve and the flow of blood within the heart.

A. Check MAR for antianxiety medication B. Ask when the dyspnea started C. Notify the provider D. Increase oxygen from 3L/minute to 5L/minute

Correct Answer is D

Explanation

In this scenario, the client is exhibiting signs of severe respiratory distress, which could indicate worsening acute heart failure and potential respiratory failure.

a. Check MAR for antianxiety medication: While anxiety may exacerbate the client's symptoms, the priority at this moment is to address the acute respiratory distress and ensure adequate oxygenation. Checking the medication administration record (MAR) for antianxiety medication can be done later but is not the immediate priority.

b. Ask when the dyspnea started: While obtaining a thorough history is important for understanding the onset and progression of the client's symptoms, it is not the first action to take in this critical situation. The client's current condition requires immediate intervention to ensure adequate oxygenation and stabilization.

c. Notify the provider: Notifying the provider is important, especially in a situation where the client's condition is deteriorating rapidly. However, this action may take some time, and the priority is to address the client's immediate needs first.

d. Increase oxygen from 3L/minute to 5L/minute: This is the most appropriate action to take first. The client is showing signs of severe respiratory distress with cyanosis and increased work of breathing. Increasing the oxygen flow rate from 3L/minute to 5L/minute can help improve oxygenation and alleviate hypoxemia, which is crucial in the management of acute heart failure exacerbation.

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The nurse is caring for a client after percutaneous coronary revascularization (PCR) via left groin site. Which assessments would the nurse obtain after the procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with mitral stenosis asks the nurse what is wrong with her heart. How can the nurse best explain this health problem?

Correct Answer is D

Explanation

A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

Correct Answer is D

Explanation

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The nurse is assessing a client who had valve replacement surgery yesterday. It would be a priority for the nurse to report which assessment finding to the healthcare provider?

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