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 B

Explanation

A. An increase in O2 saturation to greater than 90%: An increase in oxygen saturation is typically a positive sign and does not indicate worsening heart failure.

B. The onset of atrial fibrillation: The development of atrial fibrillation (AFib) in a patient with heart failure is a sign of worsening heart failure, as it indicates increased atrial pressure and the potential for further hemodynamic compromise.

C. Louder S1 and S2 heart sounds: Louder heart sounds do not specifically indicate worsening heart failure. They may vary based on other factors such as body habitus or the position of the patient.

D. A decrease in heart rate to 66 bpm: A heart rate of 66 bpm is within the normal range and does not suggest worsening heart failure.

A. Performing a 12-lead ECG B. Administering NTG to see if the pain goes away C. Gathering a complete medical history D. Asking the patient if performing a Valsalva maneuver reduces the pain

Correct Answer is A

Explanation

A. Performing a 12-lead ECG: An ECG is the most definitive and immediate tool to determine if chest pain is cardiac in origin, as it can detect ischemic changes, arrhythmias, or other cardiac abnormalities.

B. Administering NTG to see if the pain goes away: While nitroglycerin (NTG) may relieve ischemic chest pain, it is not definitive for diagnosing the pain's origin and should not be the first step without further assessment.

C. Gathering a complete medical history: Although a medical history is important, it will not immediately determine if the pain is cardiac in origin.

D. Asking the patient if performing a Valsalva maneuver reduces the pain: The Valsalva maneuver is not a reliable method to differentiate cardiac from non-cardiac chest pain and could potentially worsen certain conditions.

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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)

Nursing Test Bank

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