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Questions and Answers
A patient in the cardiac unit presents with a blood pressure of 200/130 mmHg, severe headache, and blurred vision. Which intervention should be prioritized?
A patient in the cardiac unit presents with a blood pressure of 200/130 mmHg, severe headache, and blurred vision. Which intervention should be prioritized?
- Initiating immediate blood pressure control measures. (correct)
- Administering routine oral antihypertensive medication.
- Monitoring the patient for any further changes.
- Educating the patient on lifestyle modifications.
A patient who underwent a cardiac catheterization two hours ago is complaining of increasing pain at the insertion site. What is the nurse's priority action?
A patient who underwent a cardiac catheterization two hours ago is complaining of increasing pain at the insertion site. What is the nurse's priority action?
- Administer oral pain medication and elevate the affected extremity.
- Assess the insertion site for bleeding or hematoma and check distal pulses. (correct)
- Notify the provider for a prescription of intravenous pain medication.
- Document the patient's complaint and reassess in an hour.
During evening rounds, a nurse finds a patient unresponsive and without a pulse. What is the first action the nurse should take?
During evening rounds, a nurse finds a patient unresponsive and without a pulse. What is the first action the nurse should take?
- Check the patient's medication list.
- Administer oxygen via nasal cannula.
- Prepare to administer intravenous fluids.
- Start CPR and call for help. (correct)
A patient with a history of heart failure is admitted with increased shortness of breath and pink, frothy sputum. Which intervention is the priority for this patient?
A patient with a history of heart failure is admitted with increased shortness of breath and pink, frothy sputum. Which intervention is the priority for this patient?
A patient in the cardiac unit is diagnosed with new-onset atrial fibrillation with rapid ventricular response (RVR). What is the immediate concern for this patient?
A patient in the cardiac unit is diagnosed with new-onset atrial fibrillation with rapid ventricular response (RVR). What is the immediate concern for this patient?
Flashcards
ABC approach
ABC approach
Prioritize patients with airway, breathing, and circulation issues first.
Cardiac Arrest
Cardiac Arrest
Unresponsive, no pulse. Requires immediate CPR and help.
Acute Myocardial Infarction (MI)
Acute Myocardial Infarction (MI)
Chest pain, sweating, shortness of breath. Requires MONA (Morphine, Oxygen, Nitrates, Aspirin).
Pulmonary Edema
Pulmonary Edema
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Hypertensive Crisis
Hypertensive Crisis
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Study Notes
- Prioritize cardiac patients using ABC (Airway, Breathing, Circulation) and triage principles.
Life-Threatening Emergencies (Immediate Attention)
- Cardiac Arrest: Requires immediate CPR and calling for help due to unresponsiveness and absence of pulse.
- Acute Myocardial Infarction (MI/Heart Attack): Requires MONA (Morphine, Oxygen, Nitrates, Aspirin) for chest pain, diaphoresis, SOB, and nausea.
- Severe Arrhythmias (V-tach, V-fib, symptomatic bradycardia): Necessitates defibrillation, pacing, or medication.
- Pulmonary Edema/Severe Heart Failure: Requires oxygen, diuretics, and vasodilators for pink frothy sputum and severe SOB.
- Hypertensive Crisis: Requires immediate BP control for BP >180/120 with organ damage signs.
High-Risk Patients (Urgent)
- Unstable Angina: Characterized by chest pain at rest or worsening symptoms.
- Post-Cath/Post-Surgery Patients: Monitored for bleeding, hematoma, or occlusion.
- New-Onset Atrial Fibrillation (A-Fib) with RVR: Monitored for risk of stroke and hemodynamic instability.
- Heart Failure Exacerbation: Characterized by fluid overload with stable vital signs.
- DVT/PE Suspicion: Indicated by leg swelling, chest pain, and tachycardia.
Stable Patients (Routine Monitoring)
- Post-MI Recovery Patients: Require monitoring despite stability.
- Controlled Arrhythmias: Asymptomatic patients managed with medication.
- CHF Patients with No Acute Distress: Focus on education and medication adjustment.
Discharge Planning and Education
- Focus on stable patients preparing for discharge.
- Includes teaching about medications, lifestyle changes, and follow-ups.
Key Considerations
- Continuously assess vital signs and patient symptoms.
- Use SBAR (Situation, Background, Assessment, Recommendation) for communication.
- Reassess patients frequently due to rapidly changing conditions.
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