2025\2026 A+ Grade
A client recovering from a percutaneous coronary intervention (PCI) after an acute myocardial infarction
is being transferred from the PACU to the Cardiac ICU. Which assessment finding should the PACU nurse
inform the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay
- correct answer a. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
What is the preferred treatment of an acute MI within 12 hours of symptom onset?
- correct answer PCI; places a stent in the affected coronary artery
How often must a PCI pressure dressing site be assessed?
- correct answer q30min for 4 hours
qh thereafter
Central Venous Pressure (CVP)
- correct answer the pressure of blood in the thoracic vena cava, near the right atrium of the heart;
reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into
the arterial system; normal is 2-6 mmHg
Sensitivity of a pacemaker
- correct answer pacing devices ability to detect what electrical activity is being generated by the
patient's heart to prevent any competition between the hearts intrinsic activity
, Contrast Induced Nephropathy (CIN)
- correct answer A sudden deterioration in renal function that is caused by intravascular administration
of iodinated contrast medium; typically seen with angiplasty/angiography
Signs of tension pneumothorax
- correct answer 1. affected side will have decreased or absent lung sounds
2. cyanosis
3. Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
Pneumatic Antishock Garment
- correct answer An inflatable device that covers the legs and abdomen; used to splint the lower
extremities or pelvis, or to control bleeding in the lower extremities or pelvis.
- used for intraperitoneal hemorrhage
What is the expected ABG of a pulmonary embolism?
- correct answer Tachypnea and tachycardia--> respiratory alkalosis
A client is brought to the emergency department following a motor vehicle accident. Initial assessment
reveals that the client is unconscious with a blood pressure of 165/73 mmHg, HR 50 bpm, RR 8 and
irregular, temperature of 103 F. What do you suspect is happening?
- correct answer The findings reveal Cushing's Triad (hypertension with widening pulse pressure,
bradycardia and bradypnea); this indicates increased ICP
Symptoms of Right Ventricular Hypertrophy
- correct answer fatigue, swelling, weakness, chest pain, SOB, dizziness
The nurse is caring for a client who is being weaned from mechanical ventilation. Which assessment
finding indicates that the client is ready to the the endotracheal tube removed?
- correct answer - pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure