The nurse is caring for a client three hours after percutaneous coronary intervention (PCI) with stent placement. The client now complains of 5/10 chest pain. The client is visibly diaphoretic and anxious. The ECG shows ST segment elevations. The vital signs are as follows: BP: 156/82, HR: 110, RR: 20, T: 98.6, and Sp02: 94% on 2L nasal canula. The nurse anticipates which intervention in this situation?

Fluid bolus and IV heparin

A medical prescription for a stat chest x-ray

Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours

Repeat PCI with thrombectomy or angioplasty

Answer and Explanation

The Correct Answer is D

A) Fluid bolus and IV heparin:
A fluid bolus and IV heparin may be used in certain cardiovascular conditions, such as hypotension or in the setting of acute coronary syndrome (ACS) to prevent clot formation. However, in this case, the client is experiencing chest pain with ST segment elevations, a sign of ongoing ischemia, which suggests that the problem may be related to inadequate blood flow to the heart. Fluid boluses could exacerbate the condition if the heart's function is compromised, and IV heparin alone would not address the root cause of the ischemia. Hence, this is not the most appropriate intervention at this time.

B) A medical prescription for a stat chest x-ray:
A chest x-ray would not be immediately indicated in this scenario. The client's symptoms of chest pain, diaphoresis, and ST segment elevations on the ECG are indicative of myocardial ischemia or infarction, not a respiratory or structural lung issue that would be visualized on an x-ray. The priority here is to address the myocardial ischemia, which could be due to a clot or reocclusion in the coronary artery. A stat chest x-ray would not address the underlying cardiac issue, so this is not the best choice.

C) Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours:
While CABG is an option for clients with severe coronary artery disease, it is generally considered when PCI is not successful or when there are multiple blockages that cannot be stented. In this situation, since the client has just undergone PCI and is now experiencing signs of reocclusion (e.g., chest pain, ST segment elevations), a repeat PCI with thrombectomy or angioplasty is more appropriate and urgent. Waiting 12 hours would delay treatment and risk further myocardial damage. CABG would not be the first intervention after a failed PCI within hours of the procedure.

D) Repeat PCI with thrombectomy or angioplasty:
This is the most appropriate intervention. The client's symptoms (chest pain, diaphoresis, and ST segment elevations) are suggestive of reocclusion of the stented artery, a complication that can occur after PCI. Reocclusion can cause further myocardial ischemia and infarction. A repeat PCI with thrombectomy or angioplasty would aim to reopen the blocked artery and restore blood flow to the myocardium, which is the immediate priority in this situation. This intervention can help resolve the ischemia and prevent further damage to the heart muscle.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. pH 7.33, PaCO2 35 mmHg, PaO2 78 mmHg, HCO3 20 mEq/L:
This answer choice indicates respiratory acidosis (pH < 7.35, low bicarbonate), but the goal in acute respiratory failure is not just to adjust the pH alone; the more immediate concern is correcting oxygenation. The PaO2 of 78 mmHg is below the normal range (80-100 mmHg), indicating hypoxemia that should be corrected first. The goal should be to improve PaO2 to acceptable levels (≥80 mmHg) and achieve adequate oxygen saturation. This ABG result does not fully align with the immediate goals of treatment.

B. Heart rate 80 and respiratory rate 20:
While normal vital signs like heart rate and respiratory rate are important, they are not the primary goal of treatment in acute respiratory failure. The focus during ventilator support is to improve oxygenation and ventilation rather than simply achieving normal heart and respiratory rates. In acute respiratory failure, abnormal heart and respiratory rates are often a result of hypoxia or hypercapnia (high CO2), so normalizing oxygenation and carbon dioxide levels is more critical initially.

C. O2 saturation of at least 94%:
The primary goal in acute respiratory failure is to maintain adequate oxygenation. In this context, the goal of ventilator support is to correct hypoxemia (low blood oxygen levels) and restore normal oxygen saturation. A target oxygen saturation of at least 94% is commonly considered appropriate for most patients in acute respiratory failure to ensure that tissues are receiving enough oxygen to prevent organ damage. This is a key aspect of managing respiratory failure and ensuring adequate tissue perfusion. Oxygen saturation below 90% is typically considered to indicate a severe level of hypoxemia, requiring prompt intervention.

D. Sodium 135 mg/dL and potassium 4.8 mg/dL:
While electrolyte levels are important to monitor in any critically ill patient, the main goal of treatment in acute respiratory failure is improving oxygenation and ventilation rather than focusing specifically on normalizing sodium or potassium levels. Correcting imbalances in electrolytes can be part of overall care, but it is not the primary objective in this situation. Oxygenation (as measured by PaO2 and O2 saturation) takes priority over correcting individual electrolytes.

A. similar to the angina attacks you had in the past." B. a condition characterized by coronary arteries vasodilating." C. a term used to describe an irregular heartbeat." D. is a less severe type of heart attack compared to STEMI."

Correct Answer is D

Explanation

A. Similar to the angina attacks you had in the past:
This response is not entirely accurate. Angina refers to chest pain that occurs when the heart's demand for oxygen exceeds its supply, usually due to partial blockage of the coronary arteries. NSTEMI (non-ST elevation myocardial infarction) is different from angina in that it involves actual heart muscle injury or damage due to partial or intermittent blockage of a coronary artery, whereas angina does not cause permanent heart muscle damage. Therefore, describing NSTEMI as similar to past angina attacks would be misleading.

B. A condition characterized by coronary arteries vasodilating:
This is incorrect. NSTEMI occurs due to a partial blockage or narrowing of the coronary arteries, usually caused by a blood clot that forms around a ruptured atherosclerotic plaque. The blockage restricts blood flow to the heart muscle, causing injury or infarction. Vasodilation (the widening of blood vessels) is not a characteristic of NSTEMI; in fact, it is the constriction or blockage of the coronary arteries that leads to this type of heart attack.

C. A term used to describe an irregular heartbeat:
This is incorrect. NSTEMI is not related to an irregular heartbeat or arrhythmia directly. While arrhythmias (irregular heartbeats) can occur as a result of a heart attack, NSTEMI specifically refers to a type of heart attack that is not accompanied by the characteristic ST-segment elevation seen on an electrocardiogram (ECG) in a STEMI (ST-elevation myocardial infarction). It indicates a partial blockage of a coronary artery and is generally less severe than STEMI.

D. Is a less severe type of heart attack compared to STEMI:
This is the most accurate response. NSTEMI is a type of heart attack that is often considered less severe than STEMI, but still involves heart muscle injury. The difference between NSTEMI and STEMI lies in the ECG findings: STEMI involves a full-thickness myocardial infarction with a significant blockage of the artery, as indicated by ST-segment elevation on an ECG. In NSTEMI, there is a partial blockage or temporary decrease in blood flow, and the ST-segment does not elevate on the ECG, but biomarkers (like troponin) are elevated, indicating heart muscle damage. NSTEMI is often less severe in terms of the extent of damage compared to STEMI, but it still requires urgent treatment to prevent further complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The client tells the nurse, "My physician told me that I had a non-ST elevation myocardial infarction (NSTEMI). " I thought all heart attacks were the same. Can you explain this to me?" The nurse's best response to the client's question would be: "NSTEMI is

Correct Answer is D

Explanation

Which nursing intervention is the highest priority for the client who has had an acute anterior wall myocardial infarction?

Which method would the nurse utilize to best facilitate communication when caring for a client with end stage amyotrophic lateral sclerosis (ALS)?

Which of the following assessment findings in a client who is receiving atenolol for angina would be a cause for the nurse to hold the medication and contact the provider?

What is the first action the nurse should take with the accidental dislodgement of a chest tube?

The nurse is caring for a client diagnosed with acute respiratory failure as a result of right middle and lower lobe pneumonia. To optimize ventilation and secretion removal the nurse should position the client:

The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS) who requires mechanical ventilation. A client problem of decreased cardiac output from the positive pressure ventilator has been identified. What should the nurse include in the plan of care? Assess: