Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She sta
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Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, "It just gets worse and worse." Ms. S has been under a physician's care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker, but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken.
Ms. S's CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg
Heart rate 120 to 130 beats/min, irregular
O2 saturation 94% on room air
Respiratory rate 30 to 34 breaths/min
Temperature 99.8° F (37.7° C) (oral) - ANSWER
Which action may you delegate to a UAP caring for Ms. S?
1. Placing the client on a cardiac telemetry monitor
2. Drawing blood to test cardiac marker levels and sending it to the laboratory
3. Obtaining a 12-lead ECG
4. Monitoring and recording the client's intake and output - ANSWER Monitoring and recording the client's intake and output
Rationale:
Monitoring and recording intake and output are within the scope of practice for UAPs. Initiating telemetry, performing venipuncture, and obtaining ECGs require additional education and training. Attaching ECG leads may be done by UAPs in some facilities, as may venipuncture and ECG recording. However, the UAPs performing these tasks would require additional specialized training. These actions are generally considered to be within the scope of practice of licensed nurses.
Focus: Delegation
QSEN: Teamwork & Collaboration
Concept: Collaboration
Which physician order takes first priority at this time?
1. Measure vital signs every 2 hours.
2. Obtain a 12-lead ECG every 6 hours.
3. Place the client on a cardiac monitor.
4. Check levels of cardiac markers every 6 hours. - ANSWER Place the client on a cardiac monitor.
Rationale:
Cardiac monitoring is the highest priority, because the client's heart rate is rapid and irregular and the client is experiencing chest pressure. The client is at risk for life-threatening dysrhythmias such as frequent premature ventricular contractions (PVCs). Measuring vital signs every 2 hours, checking levels of cardiac markers, and recording a 12-lead ECG every 6 hours are important, but cardiac monitoring takes precedence.
Focus: Prioritization
QSEN: Patient-Centered Care, Safety
Concept: Clinical Judgment
The client's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs). Which drug should you prepare to administer first?
1. Amiodarone (Cordarone) IV push
2. Nitroglycerin (Nitrostat) sublingually
3. Morphine sulfate IV push
4. Atenolol (Tenormin) IV push - ANSWER Amiodarone (Cordarone) IV push
Rationale:
With frequent PVCs, the client is at risk for life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Amiodarone is an antidysrhythmic drug used to control ventricular dysrhythmias. Nitroglycerin and morphine can be given for chest pain relief. Atenolol is a beta-blocker, which can be used to control heart rate and decrease blood pressure.
Focus: Prioritization
QSEN: Safety
Concept: Safety
All of these laboratory values were obtained in the ED. Which value has immediate implications for the care of this client?
1. Potassium level of 3.4 mEq/L
2. Troponin T level of more than 0.20 ng/mL
3. Glucose level of 123 mg/dL
4. Slight elevation of white blood cell count - ANSWER Troponin T level of more than 0.20 ng/mL
Rationale:
A troponin T level of more than 0.20 ng/mL is an elevated level and indicates myocardial injury or infarction. Although the other laboratory values are all abnormal, none of them is life threatening.
Focus: Prioritization
QSEN: Safety
Concept: Safety
Ms. S reports worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and you notify the health care provider. Which order takes priority at this time?
1. Administer morphine sulfate 2 mg IV push.
2. Schedule an echocardiogram.
3. Draw blood for coagulation studies.
4. Administer ranitidine (Zantac) 75 mg orally every 12 hours. - ANSWER Administer morphine sulfate 2 mg IV push.
Rationale:
Morphine sulfate has been ordered to relieve the chest discomfort that is common in the setting of acute myocardial infarction. Relief from the chest pain is the highest priority at this time. Ranitidine is a histamine2 blocker used to prevent gastric ulcers. Scheduling an echocardiogram or drawing blood for coagulation studies, although important, will not help relieve chest discomfort.
Focus: Prioritization
QSEN: Patient-Centered Care, Safety
Concept: Clinical Judgment
Because Ms. S continues to experience chest pain and has elevated levels of cardiac markers, the following interventions have been ordered. Which interventions may you assign to an experienced UAP? (Select all that apply.)
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