Practice Quiz

CCRN Critical Care Nursing

Category - Adult

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An intensive care nurse answers a rapid response call for a 54 year old female patient on the pre-surgery floor who is scheduled to have a left partial knee replacement later today. When the nurse arrives, she notes the ashen color of the woman’s face and profuse sweating. The monitor shows a blood pressure of 170/90, a heart rate of 122 and an oxygen saturation of 92% on 1 liter of oxygen. The admitting nurse states that the woman had been complaining of nausea. What is the most likely cause of the patient’s condition?
  1. Pulmonary embolism
  2. Myocardial infarction
  3. Cardiac tamponade
  4. Anxiety attack
Explanation
Answer: B - The most likely cause of the patient’s condition is the myocardial infarction. Many people who have a myocardial infarction experience symptoms such as indigestion or “just not feeling well.” Because of the peripheral vasoconstriction occurring in the body, the skin will look pale or ashen. The increase of catecholamine is taken as a response to the heart attack causing tachycardia, anxiety and palpitations.
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