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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
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.
Correct Answer is A
Explanation
A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.
B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.
C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.
D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.
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