When caring for a patient with ACS (Acute Coronary Syndrome) who has returned to the coronary care unit after having a PCI (percutaneous coronary intervention), the nurse obtains these assessment data. Which piece of data indicates the need for immediate intervention by the nurse?
Blood pressure 104/56 mm Hg
Chest pain level 8 on a 10-point scale
Pedal pulses 2+
Heart rate 100 bpm
The Correct Answer is B
A. Blood pressure 104/56 mm Hg: This blood pressure is slightly below the normal range but may be acceptable post-PCI, depending on the patient’s baseline and clinical stability. Mild hypotension should be monitored, but it does not typically require immediate intervention unless accompanied by symptoms of shock or organ hypoperfusion.
B. Chest pain level 8 on a 10-point scale: Severe chest pain after PCI is a critical warning sign of potential complications such as acute stent thrombosis, coronary artery re-occlusion, or myocardial ischemia. Immediate intervention is necessary, including notifying the provider, assessing vital signs, and preparing for possible reperfusion therapy or emergent measures.
C. Pedal pulses 2+: Palpable, strong pedal pulses indicate adequate peripheral perfusion. This assessment finding is reassuring and does not necessitate immediate intervention, though ongoing monitoring of circulation distal to the access site is important.
D. Heart rate 100 bpm: A heart rate of 100 bpm is at the upper limit of normal and may reflect mild post-procedural stress, anxiety, or pain. While it requires monitoring, it is not an immediate threat to the patient’s stability in comparison to severe chest pain post-PCI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Convert ounces/cups to mL
1 cup coffee = 240 mL
3-oz juice = 3 × 30 mL
= 90 mL
240 mL milk = 240 mL
210 mL milkshake = 210 mL
12-oz tea = 12 × 30 mL
= 360 mL
3-oz jello = 3 × 30 mL
= 90 mL
12-oz cola = 12 × 30 mL
= 360 mL
Water with meds = 150 mL
Calculate total oral intake
Total intake = 240 + 90 + 240 + 210 + 360 + 90 + 360 + 150
= 1740 mL
Correct Answer is ["A","B"]
Explanation
A. is relieved by nitroglycerine: Stable angina is typically predictable and relieved by rest or sublingual nitroglycerin within minutes. The ability of nitroglycerin to quickly alleviate the pain suggests myocardial oxygen demand–supply mismatch without acute myocardial injury, distinguishing it from myocardial infarction pain, which is often persistent and unrelieved by nitroglycerin.
B. is precipitated by physical or emotional exertion: Pain that occurs with exertion or emotional stress is characteristic of stable angina. The predictable pattern and resolution with rest or medication reflect temporary myocardial ischemia rather than the prolonged ischemia and cellular injury seen in myocardial infarction.
C. does not radiate to the neck, back, or arms: Radiation of pain is not a reliable differentiator between stable angina and myocardial infarction. Stable angina can also radiate, and the absence of radiation does not confirm its presence or distinguish it from infarction.
D. is a sensation of tightness or squeezing: The quality of the pain alone cannot differentiate stable angina from myocardial infarction, as both can present with tightness, pressure, or squeezing sensations. Additional features like triggers, duration, and response to nitroglycerin are needed for differentiation.
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