The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Monitoring the skin color and turgor

Monitoring the blood pressure every fifteen minutes.

Monitoring the cardiac enzymes every eight hours

Performing neurological checks every fifteen minutes

Answer and Explanation

The Correct Answer is B

A) Monitoring the skin color and turgor:
While monitoring skin color and turgor is important in assessing fluid status and perfusion, it is not the immediate priority following an intracoronary stent insertion. Skin turgor is more useful in assessing dehydration or hypovolemia, but after a stent placement, the priority is to ensure the client is stable hemodynamically and there are no complications such as bleeding or thrombosis at the insertion site.

B) Monitoring the blood pressure every fifteen minutes:
Following an intracoronary stent insertion, it is crucial to monitor the client's blood pressure closely, as this procedure can lead to complications such as bleeding, clot formation, or vessel rupture. Monitoring blood pressure frequently (every 15 minutes initially) helps detect any signs of hypotension or hypertension that may indicate complications like bleeding or a clot.

C) Monitoring the cardiac enzymes every eight hours:
Cardiac enzymes, such as troponin, are typically used to assess myocardial injury and can be elevated in the setting of acute coronary syndrome. However, this is not the immediate priority post-procedure. The primary concern immediately after an intracoronary stent insertion is ensuring hemodynamic stability and preventing complications such as bleeding or thromboembolism, rather than focusing solely on enzyme levels.

D) Performing neurological checks every fifteen minutes:
Neurological checks are important in cases of stroke, neurological compromise, or complications like a clot dislodging. However, in the context of a patient who has just had an intracoronary stent placement, neurological checks are not the immediate priority unless there are signs of neurological symptoms (such as sudden weakness or confusion) that indicate a complication like an embolism or stroke.

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Correct Answer is D

Explanation

A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.

B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.

C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).

D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.

A. Blood pressure 102/78 B. Pulse oximetry 95% C. Crackles at bilateral bases D. Heart rate 105 beats per minute

Correct Answer is C

Explanation

A) Blood pressure 102/78:
This blood pressure is within an acceptable range, especially after resuscitation with fluids and blood products. While hypotension is a concern in hypovolemic shock, this blood pressure is stable and does not indicate an immediate need for intervention. Blood pressure monitoring is essential, but this finding is not as urgent as other options.

B) Pulse oximetry 95%:
A pulse oximetry reading of 95% is generally considered within normal limits for a patient who has undergone resuscitation and is stable. Oxygen saturation levels should be monitored, but this finding does not indicate an immediate need for intervention. Values below 90% would be more concerning, especially in trauma patients, but 95% is acceptable.

C) Crackles at bilateral bases:
The presence of crackles at the bilateral lung bases is a sign of pulmonary edema, which can occur as a result of fluid overload, especially after aggressive resuscitation with fluids like lactated Ringer's solution (LR) and blood products. In hypovolemic shock, rapid infusion of fluids can overwhelm the heart's ability to handle the volume, leading to fluid accumulation in the lungs. This finding is concerning because it can indicate a shift from hypovolemic shock to a state of volume overload, which can worsen respiratory function and lead to acute respiratory distress syndrome (ARDS).

D) Heart rate 105 beats per minute:
A heart rate of 105 beats per minute is slightly elevated but can be expected in a patient who has experienced trauma and is undergoing fluid resuscitation. Tachycardia is often seen in hypovolemic shock as the body compensates for decreased circulating volume. While monitoring the heart rate is important, this finding does not indicate an immediate life-threatening concern compared to crackles in the lungs, which suggest pulmonary edema.

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The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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