A nurse is caring for Mr. Thompson, who has just completed a cardiac stress test and is now exhibiting signs of myocardial ischemia. Which of the following actions should the nurse prioritize to address his current condition?

C) Increase the oxygen flow rate to maintain saturation above 94%.

A) Administer a second dose of sublingual nitroglycerin.

B) Prepare Mr. Thompson for immediate transport to the cardiac catheterization lab.

C) Increase the oxygen flow rate to maintain saturation above 94%.

D) Place Mr. Thompson in a supine position to enhance blood flow to the heart.

A nurse is caring for Mr. Thompson, who exhibited signs of myocardial ischemia during a cardiac stress test that was subsequently halted. Despite initial pharmacological intervention with nitroglycerin, his symptoms persist, and significant ST-segment depression remains on the ECG. Which nursing intervention is the most appropriate to prioritize at this time?

C) Prepare the patient for potential urgent coronary angiography as ordered by the physician.

A) Administer a second dose of nitroglycerin and reassess the patient's symptoms.

B) Increase the patient's oxygen flow to 6 liters per minute via nasal cannula.

C) Prepare the patient for potential urgent coronary angiography as ordered by the physician.

D) Encourage the patient to perform relaxation techniques to reduce anxiety and improve oxygenation.

Mr. Thompson, diagnosed with a non-ST elevation myocardial infarction (NSTEMI), suddenly experiences severe chest pain, diaphoresis, a blood pressure drop to 110/70 mmHg, and an irregular heart rate of 140 bpm. Considering his current condition and treatment plan, what is the most appropriate immediate nursing intervention?

B) Increase the rate of intravenous fluids.

A) Administer a second dose of nitroglycerin sublingually.

B) Increase the rate of intravenous fluids.

C) Prepare for immediate defibrillation.

D) Notify the physician for potential initiation of beta-blocker therapy.

Mr. Thompson, a patient with confirmed NSTEMI, suddenly experiences severe chest pain, diaphoresis, and an irregular heart rate of 140 bpm. As the nurse, what is the most appropriate initial action to take in this situation?

C) Notify the physician immediately and prepare for possible advanced cardiac life support.

A) Administer a beta-blocker to control the heart rate.

B) Increase the rate of intravenous fluids to manage blood pressure.

C) Notify the physician immediately and prepare for possible advanced cardiac life support.

D) Administer an additional dose of nitroglycerin to relieve chest pain.

A nurse is caring for Mr. Thompson, who is experiencing hemodynamic instability following an NSTEMI. His potassium level is 3.2 mmol/L, and he presents with frequent premature ventricular contractions (PVCs). Which priority intervention should the nurse anticipate to address Mr. Thompson's condition effectively?

C) Initiate potassium replacement therapy to correct the electrolyte imbalance.

A) Administer a beta-blocker to control the heart rate.

B) Prepare for immediate cardioversion to address the PVCs.

C) Initiate potassium replacement therapy to correct the electrolyte imbalance.

D) Increase intravenous fluid administration to improve blood pressure.

A nurse is caring for Mr. Thompson, who is experiencing hemodynamic instability and frequent premature ventricular contractions (PVCs) after an NSTEMI. His potassium level is 3.2 mmol/L, and he has a creatinine level of 1.5 mg/dL. Which nursing intervention should the nurse prioritize to address Mr. Thompson's condition?

B) Begin potassium replacement therapy to correct hypokalemia.

A) Administer intravenous normal saline to increase blood pressure.

B) Begin potassium replacement therapy to correct hypokalemia.

C) Prepare for immediate defibrillation due to PVCs.

D) Administer a rapid bolus of an anti-arrhythmic agent.

During Mr. Thompson's pre-coronary angiography preparation, the team prioritizes the management of his condition. Which intervention is most critical to prevent further myocardial ischemia given his current symptoms and vital signs?

A) Administering an intravenous potassium infusion

B) Providing a cautious bolus of a beta-blocker

C) Initiating a rapid infusion of normal saline

D) Administering sublingual nitroglycerin

Mr. Thompson, experiencing worsening chest pain and arrhythmias, is being prepared for coronary angiography. The medical team decides to stabilize his condition by addressing potential causes of arrhythmias. Which of the following interventions is most critical to implement first to prevent further complications?

B) Start an infusion of intravenous potassium to address hypokalemia

A) Administer a bolus of intravenous fluids to support blood pressure

B) Start an infusion of intravenous potassium to address hypokalemia

C) Administer a cautious dose of a beta-blocker to control heart rate

D) Prepare for immediate coronary angiography to assess blockages

Mr. Thompson is about to undergo coronary angiography due to elevated troponin levels and suspected acute myocardial ischemia. Considering his current hemodynamic status, which nursing intervention is most critical to prioritize immediately before the procedure?

D) Initiate continuous cardiac monitoring to observe for arrhythmias.

A) Administer a dose of beta-blockers to decrease the heart rate.

B) Infuse intravenous fluids to improve blood pressure.

C) Provide supplemental potassium to correct the electrolyte imbalance.

D) Initiate continuous cardiac monitoring to observe for arrhythmias.

A nurse is reviewing the plan of care for Mr. Thompson, who is undergoing coronary angiography due to elevated troponin levels indicating myocardial injury. Which nursing intervention is most critical to prioritize during the procedure?

C) Continuously assessing cardiac rhythm and hemodynamic status.

A) Administering supplemental potassium to correct hypokalemia.

B) Monitoring for signs of bleeding at the catheter insertion site.

C) Continuously assessing cardiac rhythm and hemodynamic status.

D) Educating Mr. Thompson about post-procedure lifestyle modifications.

cardiac stress testing - Nursing Case Study

Pathophysiology

• Primary mechanism: During cardiac stress testing, increased heart workload is induced through exercise or pharmacological agents, revealing ischemia by assessing coronary artery perfusion. This helps identify obstructive coronary artery disease as narrowed arteries fail to meet myocardial oxygen demand during stress.

• Secondary mechanism: The test evaluates cardiac function by monitoring changes in heart rate, blood pressure, and electrocardiogram (ECG) patterns. Abnormalities such as ST-segment changes on the ECG can indicate inadequate blood flow to the heart muscle, signaling potential ischemia.

• Key complication: If coronary arteries are significantly narrowed, stress testing can provoke angina or other ischemic symptoms, providing critical insight into the severity of coronary disease and guiding further diagnostic or therapeutic interventions.

Patient Profile

Demographics:

52-year-old male, construction worker

History:

• Key past medical history: Hypertension, Hyperlipidemia

• Current medications: Lisinopril 10 mg daily, Atorvastatin 20 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath during physical activity

• Key symptoms: Fatigue, dizziness, palpitations

• Vital signs: Blood pressure 150/95 mmHg, Heart rate 105 bpm, Respiratory rate 22 breaths per minute, Oxygen saturation 94% on room air, Temperature 98.6°F (37°C)

Section 1

As the cardiac stress test progresses, the patient, Mr. Thompson, begins to exhibit increasing signs of distress. Approximately six minutes into the treadmill exercise, his chest pain intensifies, and he reports a sharp pain radiating to his left arm and jaw. His heart rate spikes to 135 bpm, and his blood pressure rises to 165/100 mmHg. The ECG monitor reveals significant ST-segment depression in the anterior leads, suggesting myocardial ischemia. The test is promptly halted, and Mr. Thompson is assisted to a seated position while being reassured and closely monitored.

Despite the cessation of the stress test, Mr. Thompson's symptoms do not immediately abate. His chest pain persists, and he experiences increased shortness of breath with a respiratory rate climbing to 26 breaths per minute. His oxygen saturation drops to 92% on room air. Nitroglycerin is administered sublingually, which results in a gradual improvement of his symptoms within a few minutes. However, the persistence of significant ST-segment changes on the ECG prompts further evaluation. Blood samples are drawn for cardiac biomarkers, including troponin, to assess for possible myocardial injury.

The clinical team considers the potential need for urgent coronary angiography to investigate the extent of coronary artery disease and to determine the necessity for interventions such as percutaneous coronary intervention (PCI). This decision is based on his high-risk stress test findings and the unresolved ischemic symptoms following pharmacological management. The case underscores the importance of timely intervention in the context of unstable angina and highlights the need for a strategic approach in managing potential acute coronary syndrome, balancing risks, and benefits for Mr. Thompson's condition.

Section 2

Following the initial assessment and administration of nitroglycerin, Mr. Thompson's chest pain diminishes slightly, but he remains anxious and reports intermittent palpitations. His respiratory rate stabilizes at 22 breaths per minute, and his oxygen saturation improves marginally to 94% on supplemental oxygen via nasal cannula. Despite these improvements, the ECG continues to show ST-segment depression, and his heart rate remains elevated at 125 bpm. The clinical team, recognizing the potential severity of the situation, maintains a high index of suspicion for an evolving acute coronary syndrome.

New diagnostic results from the laboratory arrive swiftly. The troponin levels are elevated at 0.12 ng/mL, confirming myocardial injury, while the creatine kinase-MB is also above normal limits. These findings suggest that Mr. Thompson is likely experiencing a non-ST elevation myocardial infarction (NSTEMI). His blood chemistry shows mild electrolyte imbalances, with a potassium level of 3.4 mmol/L, which could potentially exacerbate his cardiac symptoms. Based on these results and his persistent symptoms, the decision to proceed with urgent coronary angiography is made to assess the extent of coronary artery blockage and to guide further treatment.

As preparations for the angiography begin, Mr. Thompson's condition takes a concerning turn. He suddenly complains of a resurgence of severe chest pain and exhibits signs of diaphoresis. His blood pressure drops to 110/70 mmHg, and his heart rate increases to 140 bpm with irregular beats noted on the monitor. These changes suggest possible hemodynamic instability, prompting immediate administration of intravenous fluids and close monitoring for arrhythmias. The clinical team is now faced with the challenge of managing these new complications while ensuring timely progression to definitive diagnostic and therapeutic interventions.

Section 3

As the medical team continues to address Mr. Thompson's condition, they focus on the immediate management of his hemodynamic instability and the potential complications associated with his NSTEMI. Despite the administration of intravenous fluids, Mr. Thompson's blood pressure remains borderline, fluctuating between 105/65 mmHg and 110/70 mmHg. His heart rate persists at a worrying 140 bpm, with the telemetry monitor indicating frequent premature ventricular contractions (PVCs), raising the concern for possible progression to ventricular tachycardia. Given the combination of elevated heart rate, irregular beats, and chest pain, the team is vigilant for signs of further deterioration.

New laboratory results reveal a further drop in potassium levels to 3.2 mmol/L, necessitating prompt potassium replacement to mitigate the risk of life-threatening arrhythmias. Additionally, the medical staff reviews Mr. Thompson's renal function, noting a creatinine level of 1.5 mg/dL, which is slightly elevated, suggesting the potential for compromised renal function due to decreased perfusion. The team decides to administer an anti-arrhythmic agent cautiously, taking into account Mr. Thompson's renal status and the need to avoid exacerbating his hemodynamic instability.

Despite these challenges, preparation for the coronary angiography remains a priority. The team collaborates to stabilize Mr. Thompson sufficiently to proceed with the diagnostic procedure, aware that timely intervention is crucial in preventing further myocardial damage. As he is transferred to the catheterization lab, the healthcare providers continue to monitor his vital signs closely, ensuring that any further complications are managed swiftly and effectively. The unfolding situation necessitates ongoing clinical reasoning, balancing the urgency of addressing Mr. Thompson's acute symptoms with the need to prevent additional complications.

Section 4

As Mr. Thompson is prepped for coronary angiography, the team remains attentive to his fluctuating condition. Shortly before the procedure, a sudden change in his status prompts immediate reassessment. Mr. Thompson begins to experience worsening chest pain, now rated as 8 out of 10, and develops mild diaphoresis. His blood pressure drops to 95/60 mmHg, and his heart rate escalates to 150 bpm, with telemetry continuing to show frequent PVCs. These changes suggest possible progression of his myocardial ischemia, demanding urgent intervention to stabilize his condition before proceeding with the angiography.

In response to these developments, the medical team prioritizes the administration of intravenous potassium to address his hypokalemia, given its critical role in reducing the risk of arrhythmias. Mr. Thompson is also given a cautious bolus of a beta-blocker to help control his heart rate without compromising his already tenuous blood pressure. Concurrently, the team re-evaluates his fluid status and decides to administer a small, carefully calculated volume of fluids to support his blood pressure, always mindful of his renal function. This multifaceted approach reflects the team's clinical reasoning skills, as they balance the need to stabilize hemodynamics with the risk of exacerbating renal compromise.

As Mr. Thompson's condition gradually stabilizes, his chest pain decreases to a more manageable level of 4 out of 10, and his heart rate begins to come down to 130 bpm. His blood pressure rises slightly to 100/65 mmHg, providing a window of opportunity to proceed with the coronary angiography. The team remains vigilant, ready to address any further complications that may arise during the procedure, knowing that timely intervention is crucial in preventing further myocardial damage and optimizing his recovery trajectory.

Section 5

As the team prepares for the coronary angiography, a new set of diagnostic results adds an additional layer to Mr. Thompson's complex clinical picture. The laboratory reports indicate a significant elevation in cardiac enzymes, specifically troponin I, which has risen to 0.8 ng/mL from a baseline of 0.03 ng/mL. This finding further supports the suspicion of acute myocardial ischemia and underscores the urgency of the situation. Additionally, a repeat electrolyte panel shows that potassium levels have improved but remain slightly below the optimal threshold at 3.4 mEq/L, necessitating continued monitoring and possible further supplementation to minimize the risk of arrhythmias.

These results prompt the medical team to consider the balance between the benefit of proceeding with the angiography and the potential risks associated with Mr. Thompson's current status. The elevated troponin levels confirm myocardial injury, highlighting the need for precise intervention to restore coronary perfusion and prevent further cardiac damage. However, the team remains cautious about his still-fluctuating vital signs. Despite some stabilization, his heart rate remains elevated at 130 bpm, and his blood pressure, though slightly improved, is still on the low side at 100/65 mmHg.

With these considerations in mind, the team decides to proceed with the angiography, ready to deploy additional interventions as needed. They maintain a vigilant focus on Mr. Thompson's hemodynamic status throughout the procedure, prepared to adjust their approach based on real-time feedback and emerging data. This careful orchestration of diagnostic insight and clinical reasoning aims to optimize outcomes, paving the way for potential revascularization strategies that may emerge from the angiographic findings. The team's ability to synthesize new information and adjust their plan dynamically reflects their commitment to providing tailored, evidence-based care to navigate the complexities of Mr. Thompson's condition.