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1. A patient with a history of myocardial infarction is admitted to the
telemetry unit with chest pain and shortness of breath. The nurse obtains
the following vital signs: BP 180/100 mmHg, HR 110 bpm, RR 24
breaths/min, SpO2 92% on room air. The nurse should:
a) Administer nitroglycerin sublingually and monitor the patient's blood
pressure.
b) Apply oxygen via nasal cannula and notify the physician.
c) Perform a 12-lead ECG and prepare the patient for cardiac
catheterization.
d) Administer morphine intravenously and monitor the patient's pain level.
Answer: C
Rationale: The patient is showing signs of acute coronary syndrome
(ACS), which is a medical emergency that requires prompt diagnosis and
treatment. A 12-lead ECG can help identify the location and extent of
myocardial ischemia or infarction, and cardiac catheterization can provide
definitive diagnosis and intervention. Nitroglycerin, oxygen, and
morphine are also part of the initial management of ACS, but they are not
as urgent as ECG and catheterization.
2. A patient with a history of congestive heart failure is admitted to the
telemetry unit with worsening dyspnea, orthopnea, and peripheral edema.
The nurse auscultates crackles in both lung bases and notes a third heart
sound (S3). The nurse should:
a) Increase the rate of the intravenous diuretic and monitor the patient's
urine output.
b) Administer digoxin intravenously and monitor the patient's heart rate
and rhythm.
c) Elevate the head of the bed and administer oxygen via face mask.
d) All of the above.
Answer: D
Rationale: The patient is showing signs of acute decompensated heart
failure (ADHF), which is a worsening of chronic heart failure symptoms
that requires immediate treatment. The goals of therapy are to improve
oxygenation, reduce preload and afterload, enhance cardiac contractility,
and promote diuresis. Increasing the rate of the intravenous diuretic can
help reduce fluid overload and edema. Administering digoxin can help
increase cardiac output and decrease sympathetic activity. Elevating the
head of the bed and administering oxygen can help improve respiratoryÂ
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