Priority Decision: A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important?

Correct Answer: A

Rationale: In the context of a patient hospitalized after sudden cardiac death (SCD), the most important nursing intervention is A) Continuous ECG monitoring. This is crucial because it allows for real-time monitoring of the patient's cardiac rhythm, which is essential in detecting any potential arrhythmias or abnormalities promptly. Continuous ECG monitoring enables early identification of changes in the heart's electrical activity, which is critical in preventing another cardiac event. It provides valuable information on the patient's heart rate, rhythm, and conduction, allowing nurses to intervene promptly if any issues arise. Auscultation of the carotid arteries (Option B) may provide information on blood flow, but it does not directly monitor the patient's cardiac rhythm or electrical activity. Frequent assessment of heart sounds (Option C) is important but does not take precedence over continuous ECG monitoring in this scenario. Monitoring airway status and respiratory patterns (Option D) is essential for overall patient care, but in the immediate aftermath of SCD, ensuring continuous ECG monitoring takes priority due to the risk of recurrent cardiac events. In an educational context, understanding the rationale behind prioritizing interventions post-SCD is crucial for nurses caring for cardiac patients. It emphasizes the significance of continuous cardiac monitoring in preventing potential complications and guiding timely interventions to ensure optimal patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct nursing action is to choose option A) call Mr. K.'s physician to report the PT result. A significantly elevated prothrombin time indicates a prolonged clotting time, which may lead to an increased risk of bleeding. Therefore, it is crucial to inform the physician promptly to ensure appropriate management. Option B) stopping the heparin infusion is incorrect because heparin is an anticoagulant used to prevent blood clots, and abruptly discontinuing it can lead to an increased risk of clot formation. Option C) increasing the heparin infusion is also incorrect as it would further exacerbate the anticoagulation effect, potentially leading to serious bleeding complications. Option D) doing nothing is not the appropriate course of action when faced with a critical lab result that can impact patient safety. Educationally, understanding the significance of prothrombin time values is vital for nurses caring for patients on anticoagulant therapy. This knowledge helps in recognizing abnormal results, taking appropriate actions, and collaborating effectively with the healthcare team to ensure patient safety and optimal outcomes.

Correct Answer: C

Rationale: In the context of teaching about methyldopa to patients, it is crucial for them to understand that option C) may produce drowsiness initially is the correct answer. Methyldopa is an antihypertensive medication that acts centrally to reduce blood pressure. One of the common side effects of methyldopa is drowsiness, especially when initiating treatment. Educating patients about this potential side effect is important for them to be aware and to prevent any unnecessary concerns or alarm. Option A) decreases cardiac output is incorrect because methyldopa primarily acts on the central nervous system to reduce blood pressure and does not directly impact cardiac output. Option B) may produce mental confusion is incorrect as mental confusion is not a common side effect associated with methyldopa use. Option D) blocks the release of norepinephrine is incorrect as methyldopa works by being converted into alpha-methyl norepinephrine, which then acts in the brain to decrease sympathetic outflow, thereby lowering blood pressure. In an educational context, teaching patients about the potential side effects of medications like methyldopa empowers them to recognize and manage these effects effectively. It also fosters a sense of autonomy and responsibility in their own healthcare management. This knowledge enables patients to make informed decisions and seek timely medical advice if needed.

Correct Answer: C

Rationale: The correct answer is C) left ventricular failure. Pulmonary capillary wedge pressure (PCWP) is a measure of the pressure in the left side of the heart and reflects left ventricular function. When PCWP rises above normal values, it indicates increased pressure in the left side of the heart, which commonly occurs in left ventricular failure. This can lead to symptoms of pulmonary congestion and edema due to the backflow of blood into the lungs. Option A) right ventricular failure is incorrect because PCWP specifically reflects left ventricular function, not right ventricular function. Right ventricular failure would manifest with other signs and symptoms. Option B) hypovolemia is incorrect because in hypovolemia, the PCWP would be low rather than high. Hypovolemia indicates a decreased blood volume, leading to reduced filling pressures in the heart. Option D) ventricular irritability is incorrect as this term refers to abnormal electrical activity in the heart, such as arrhythmias, and is not directly related to PCWP levels. In an educational context, understanding the significance of monitoring PCWP is crucial in assessing cardiac function and guiding treatment in patients with heart failure. This question highlights the importance of recognizing the implications of changes in PCWP values and their correlation with specific cardiac conditions, aiding in clinical decision-making and patient management.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) 1-lb weight gain in 2 days. This is a crucial symptom that clients taking diuretics for chronic congestive heart failure need to report promptly. This rapid weight gain can indicate fluid retention, a sign that the heart failure is worsening, and immediate medical intervention may be necessary. Option B) Seeing yellow hazes around bright lights is not directly related to the management of congestive heart failure or diuretic therapy. This symptom could be indicative of other health issues but is not a typical concern for clients in this specific context. Option C) Change in the heart rate is a common symptom in heart-related conditions, but for clients taking diuretics for heart failure, changes in heart rate may not always be a primary indicator of worsening condition compared to sudden weight gain. Option D) Change in activity tolerance is a general symptom that can be seen in various health conditions. While it is important for clients with heart failure to monitor their activity tolerance, sudden weight gain is a more specific and critical indicator that requires immediate attention in this context. Educational context: It is essential for healthcare providers to educate clients with chronic congestive heart failure about the importance of monitoring their weight regularly, as it can be an early sign of fluid retention and worsening heart failure. Recognizing and reporting such changes promptly can help prevent complications and improve outcomes for individuals with heart failure.