Which of the following interventions should the nurse prioritize for a client with acute coronary syndrome who is undergoing percutaneous coronary intervention (PCI)? Select all that apply.

Educate the client on lifestyle modifications after discharge.

Transfer the client to a regular medical surgical unit after the procedure.

Evaluate the client's ECG continuously during the procedure.

Assess the client's history of bleeding and current medications.

Administer anticoagulants as prescribed.

Answer and Explanation

Correct Answer : C,D,E

Acute coronary syndrome (ACS) involves reduced blood flow to the myocardium due to partial or complete coronary artery obstruction. Percutaneous coronary intervention (PCI) is a time-sensitive procedure used to restore coronary perfusion and limit myocardial damage. During PCI, the nurse’s priority is to ensure hemodynamic stability, prevent thrombotic complications, and closely monitor for ischemic changes. Anticoagulation and continuous cardiac monitoring are essential for patient safety throughout the procedure.

Rationale:
A. Educating the client on lifestyle modifications after discharge is important but not an immediate priority during PCI. Patient education is part of long-term secondary prevention and is typically addressed after the client is stabilized. During the procedure, the focus is on real-time monitoring and acute intervention.

B. Transferring the client to a regular medical-surgical unit after the procedure is not an appropriate immediate intervention. Post-PCI clients require close monitoring in a specialized cardiac care or intensive care setting to detect complications such as bleeding, arrhythmias, or re-occlusion. Premature transfer may delay recognition of life-threatening complications.

C. Evaluating the client's ECG continuously during the procedure is essential because it allows immediate detection of ischemic changes, arrhythmias, or reperfusion events. Continuous cardiac monitoring ensures rapid intervention if complications arise during coronary artery manipulation. This is a critical safety measure in PCI.

D. Assessing the client's history of bleeding and current medications is crucial before and during PCI because anticoagulants and antiplatelet agents are used to prevent thrombus formation. Identifying bleeding risks helps guide safe medication administration and reduces the risk of hemorrhagic complications during the procedure.

E. Administering anticoagulants as prescribed is a priority because they prevent clot formation during PCI and reduce the risk of acute vessel occlusion. These medications help maintain coronary artery patency while the intervention is being performed. Proper dosing and timing are critical to ensure procedural success and patient safety.

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Correct Answer is B

Explanation

ST-segment changes on an electrocardiogram (ECG) are critical indicators of myocardial oxygenation status. ST-segment elevation in two or more contiguous leads is a hallmark finding of acute myocardial infarction, specifically ST-elevation myocardial infarction (STEMI). This reflects complete or near-complete occlusion of a coronary artery, leading to ongoing myocardial ischemia and necrosis. Prompt recognition and rapid intervention are essential to restore perfusion and limit myocardial damage.

Rationale:
A. Stable angina is characterized by transient chest pain that is typically relieved with rest or nitroglycerin and does not produce persistent ECG changes. ST-segment elevation is not a feature of stable angina. Instead, stable angina is associated with reversible myocardial ischemia without permanent tissue damage.

B. ST-segment elevation in two adjoining leads indicates an acute myocardial infarction, specifically a STEMI. This finding reflects transmural ischemia due to complete coronary artery occlusion, leading to myocardial cell death if not rapidly treated. Immediate reperfusion therapy is required to restore blood flow and limit cardiac damage.

C. A first-degree atrioventricular block is characterized by a prolonged PR interval on ECG, not ST-segment elevation. It is generally a benign conduction delay that does not indicate acute myocardial ischemia. Therefore, it is unrelated to the acute presentation described.

D. Recovery from an old myocardial infarction is typically associated with Q-wave changes rather than acute ST-segment elevation. ST elevation suggests an active, ongoing ischemic process rather than a resolved or healed event. Thus, this finding is inconsistent with a past MI recovery phase.

A. Provide education on the routine screenings by age B. Providing education on tobacco cessation C. Encouraging the client to maintain a healthy weight and stay physically active D. Suggesting that skin protection measures, such as the use of sunscreen E. Teach the client on how and when to perform breast self-examination F. Encourage hepatitis B and HPV vaccinations

Correct Answer is ["B","C","D","F"]

Explanation

Primary cancer prevention focuses on reducing exposure to risk factors and strengthening protective behaviors before cancer develops. It targets lifestyle modification, vaccination against oncogenic viruses, and avoidance of known carcinogens. These strategies aim to decrease cellular damage and mutation risk at the earliest stage of disease development. Nurses play a key role in educating clients on evidence-based preventive measures that reduce overall cancer incidence.

Rationale:
A. Providing education on routine screenings by age is not primary prevention because screening is a form of secondary prevention. Screening aims to detect cancer early, before symptoms develop, rather than preventing its occurrence. Examples include mammograms, colonoscopies, and Pap smears, which identify disease at an early stage.

B. Providing education on tobacco cessation is a primary prevention strategy because tobacco use is a major modifiable risk factor for multiple cancers, including lung, oral, and bladder cancer. Eliminating exposure to carcinogens in tobacco significantly reduces cellular damage and mutation risk. Smoking cessation also improves overall respiratory and cardiovascular health.

C. Encouraging the client to maintain a healthy weight and stay physically active is a primary prevention measure. Obesity and sedentary lifestyle are associated with increased risk for cancers such as breast, colorectal, and endometrial cancer. Regular physical activity and weight control help regulate hormones and reduce chronic inflammation linked to cancer development.

D. Suggesting skin protection measures such as sunscreen use is a primary prevention intervention. Ultraviolet (UV) radiation exposure is a major risk factor for skin cancers, including melanoma and basal cell carcinoma. Protective behaviors such as sunscreen application, protective clothing, and limiting sun exposure reduce DNA damage in skin cells.

E. Teaching the client how and when to perform breast self-examination is not considered primary prevention but rather secondary prevention. Self-examination is intended for early detection of existing abnormalities, not prevention of cancer development. It helps identify lumps or changes that may require further diagnostic evaluation.

F. Encouraging hepatitis B and HPV vaccinations is a primary prevention strategy because these infections are linked to cancers such as hepatocellular carcinoma and cervical cancer. Vaccination prevents viral infections that can lead to long-term cellular changes and malignant transformation. Immunization significantly reduces the incidence of virus-associated cancers.

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Which of the following interventions should the nurse prioritize for a client with acute coronary syndrome who is undergoing percutaneous coronary intervention (PCI)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with chest pain and an ECG shows ST-segment elevation in two adjoining leads. What does this indicate regarding the client's condition?

Correct Answer is B

Explanation

A nurse is caring for a client in an outpatient clinic who is undergoing routine screenings and lifestyle counseling. The nurse emphasized the need for annual check-ups to monitor health status. What other primary cancer prevention strategies should the nurse include? Select all that apply.

Correct Answer is ["B","C","D","F"]

Explanation

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