A patient is admitted to your acute coronary care unit with the diagnosis of ACS. The nurse has seen ECG changes that are indicative of an anterior wall infarction and is observing the patient for signs/symptoms of complications. The nurse has noted the following vital sign trends: 1100-HR 92, RR 24, BP 140/88, Cardiac rhythm NSR 1115-HR 96, RR 26, BP 128/82, Cardiac rhythm NSR 1130-HR 104, RR 28, BP 102/68, Cardiac rhythm ST 1145-HR 120, RR 32, BP 80/52, Cardiac rhythm ST with frequent PVC's The nurse should be alert for which of the following complications? Choose all that apply.

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Question 1 of 5

A patient is admitted to your acute coronary care unit with the diagnosis of ACS. The nurse has seen ECG changes that are indicative of an anterior wall infarction and is observing the patient for signs/symptoms of complications. The nurse has noted the following vital sign trends: 1100-HR 92, RR 24, BP 140/88, Cardiac rhythm NSR 1115-HR 96, RR 26, BP 128/82, Cardiac rhythm NSR 1130-HR 104, RR 28, BP 102/68, Cardiac rhythm ST 1145-HR 120, RR 32, BP 80/52, Cardiac rhythm ST with frequent PVC's The nurse should be alert for which of the following complications? Choose all that apply.

Correct Answer: C

Rationale: The correct answer is C: Cardiogenic shock. In this scenario, the patient with ACS is showing vital sign trends of decreasing blood pressure (BP) along with an increase in heart rate (HR) and respiratory rate (RR), indicating poor cardiac output. Cardiogenic shock occurs when the heart cannot pump enough blood to meet the body's demands. The decreasing BP and increasing HR are signs of impending cardiogenic shock, a serious complication of anterior wall infarction due to decreased cardiac output. Choice A: Syncope is not the most appropriate complication to be alert for in this case, as the vital signs are indicating a more severe condition than just fainting. Choice B: Pericarditis is unlikely to cause the significant changes in vital signs observed in this scenario. While pericarditis can occur following an MI, the vital sign trends are more indicative of cardiogenic shock. Choice D: Cardiac tamponade is also unlikely based on the vital sign trends provided. Card

Question 2 of 5

The nurse explains to the patient who is to undergo a coronary artery bypass graft that the procedure most often involves

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

The nurse prepares a patient for insertion of a pulmonary artery catheter. Preprocedural teaching for this client will include which of the following statements?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

At 10:00 am, a patient receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

Which type of cuff does the nurse choose to ensure an accurate assessment?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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