Chapter 35 Critical Care of Patients With Acute Coronary Syndromes.pdf

MULTIPLE CHOICE 1. A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client’s pupillary responses. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs. ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse would notify the primary health care provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Thrombolytic agents, Critical rescue MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client’s spouse asks why the client needs this medication. What response by the nurse is best? a. “The t-PA didn’t dissolve the entire coronary clot.” b. “The heparin keeps that artery from getting blocked again.” c. “Heparin keeps the blood as thin as possible for a longer time.” d. “The heparin prevents a stroke from occurring as the t-PA wears off.” ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a “blood thinner,” although laypeople may refer to it as such. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Anticoagulants MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan. ANS: B Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) GARDESLAB.COM G R A D E S L A B . C O M This client’s physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary artery disease, Activity tolerance MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best? a. “Continue to educate the client on possible healthy changes.” b. “Emphasize complications that can occur with noncompliance.” c. “Tell the client that denial is normal and will soon go away.” d. “You need to make sure the client understands this illness.” ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The nurse would not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client. DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Coronary artery disease, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atria