The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Monitoring the skin color and turgor

Monitoring the blood pressure every fifteen minutes.

Monitoring the cardiac enzymes every eight hours

Performing neurological checks every fifteen minutes

Answer and Explanation

The Correct Answer is B

A) Monitoring the skin color and turgor:
While monitoring skin color and turgor is important in assessing fluid status and perfusion, it is not the immediate priority following an intracoronary stent insertion. Skin turgor is more useful in assessing dehydration or hypovolemia, but after a stent placement, the priority is to ensure the client is stable hemodynamically and there are no complications such as bleeding or thrombosis at the insertion site.

B) Monitoring the blood pressure every fifteen minutes:
Following an intracoronary stent insertion, it is crucial to monitor the client's blood pressure closely, as this procedure can lead to complications such as bleeding, clot formation, or vessel rupture. Monitoring blood pressure frequently (every 15 minutes initially) helps detect any signs of hypotension or hypertension that may indicate complications like bleeding or a clot.

C) Monitoring the cardiac enzymes every eight hours:
Cardiac enzymes, such as troponin, are typically used to assess myocardial injury and can be elevated in the setting of acute coronary syndrome. However, this is not the immediate priority post-procedure. The primary concern immediately after an intracoronary stent insertion is ensuring hemodynamic stability and preventing complications such as bleeding or thromboembolism, rather than focusing solely on enzyme levels.

D) Performing neurological checks every fifteen minutes:
Neurological checks are important in cases of stroke, neurological compromise, or complications like a clot dislodging. However, in the context of a patient who has just had an intracoronary stent placement, neurological checks are not the immediate priority unless there are signs of neurological symptoms (such as sudden weakness or confusion) that indicate a complication like an embolism or stroke.

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Correct Answer is B

Explanation

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

A. Ventilator -associated pneumonia B. Pulmonary embolism C. Stress ulcer D. Pneumothorax

Correct Answer is A

Explanation

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

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The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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