Which of the following should the nurse assess in a patient who has just undergone a PCI (percutaneous coronary intervention) (select all that apply)

Reoccurrence of chest pain/discomfort

Puncture site for bleeding/hematoma

pulse distal to puncture site

urinary output

Answer and Explanation

Correct Answer : A,B,C

A. Reoccurrence of chest pain/discomfort: This can indicate restenosis or complications post-PCI, requiring immediate attention.

B. Puncture site for bleeding/hematoma: Bleeding at the puncture site is a common complication, so it must be closely monitored.

C. Pulse distal to puncture site: Checking the pulse distal to the puncture site helps assess for arterial occlusion or compromised blood flow, which can occur if a hematoma or clot forms.

D. Urinary output: While monitoring urinary output is important for overall assessment, it is not directly related to complications specific to PCI.

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Correct Answer is A

Explanation

A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.

B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.

C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.

D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.

A. Administer a stat fluid challenge B. Place the patient in a prone position C. Draw a stat CBC D. Perform a stat pericardiocentesis

Correct Answer is D

Explanation

A. Administer a stat fluid challenge: This might temporarily improve cardiac output in tamponade, but it is not the primary intervention. The fluid challenge may be used as a temporary measure, but it does not address the underlying cause.

B. Place the patient in a prone position: This is incorrect and could worsen the patient's condition. The patient should be in a semi-recumbent position to decrease venous return and reduce pressure on the heart.

C. Draw a stat CBC: A CBC is not relevant to the immediate management of cardiac tamponade and does not address the urgent need to relieve the pressure on the heart.

D. Perform a stat pericardiocentesis: Pericardiocentesis is the definitive treatment for cardiac tamponade, as it removes the fluid from the pericardial space, relieving the pressure on the heart and allowing it to function properly.

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Which of the following should the nurse assess in a patient who has just undergone a PCI (percutaneous coronary intervention) (select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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