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

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 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. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.

B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).

C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.

D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.