CARDIAC PT 2
A nurse working the day shift on a cardiac unit receives the following shift report: 1. Client 1: Admitted yesterday morning with hypokalemia. Awaiting repeat electrolyte lab results drawn at 06:00. 769 2. Client 2: Experienced chest pain at 06:30. Pain resolved after 2 sublingual nitroglycerin tablets. 3. Client 3: Scheduled for oral antihypertensive medications at 0900. Incontinent of urine during the night. 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The client's family is in the client's room.
2,4,3,1. Even though the chest pain experienced by Client 2 is resolved, it was recent and requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse should check this client and the client's chart and make certain that everything is ready so as to not delay the surgery. Client 3 has scheduled medications for blood pressure control. While not experiencing any acute problems, this medication should be admin
A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first? 1. Administer 2 mg morphine IV 2. Assess fingerstick blood glucose 3. Draw blood for basic metabolic panel 4. Obtain a 12-lead electrocardiogram
ANS 4 The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option 4). ST-segment elevation MI is life-threatening and requires rapid coronary intervention. (Option 1) Morphine is administered to relieve pain and anxiety. A 12-lead ECG must be obtained to verify that the symptoms are cardiac in nature before giving medications. (Option 2) In clients with diabetes, diaphoresis may indicate hypoglycemia, but other symptoms, such as epigastric pain, in this client make MI more likely. (Option 3) Nausea and generalized weakness may result from some electrolyte imbalances, and the nurse should send blood for routine studies (eg, basic metabolic panel, complete blood count). However, a 12-lead ECG will give more immediate assessment information, allowing for quicker intervention if MI is present.
A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1. If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP 2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP 3. It will be 6 months before the heart is healthy enough for sexual activity 4. The client will be ready for sexual activity after completion of cardiac rehabilitation
ANS : 1 The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely. (Option 2) The use of erectile agents is contraindicated if the client is consuming any form of nitrates. (Option 3) Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI. (Option 4) The client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity, especially if the client remains asymptomatic.
When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first? 1. Assess for jugular venous distension 2. Attach the cardiac monitor to the client 3. Auscultate heart and breath sounds 4. Obtain the client's vital signs
ANS : 2 Dysrhythmias are the most frequent complication following myocardial infarction (MI). Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in clients with MI. The nurse should attach the cardiac monitor to the client before performing any other interventions. (Option 1) Jugular venous distension may indicate development of heart failure following MI; this is an important assessment but should be performed after the cardiac monitor is attached to the client. (Options 3 and 4) Assessment of vital signs and auscultation of the heart and lungs are also important but should be performed after the cardiac monitor is attached to the client.
A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? 1. Administer digoxin 0.25 mg 2. Administer furosemide 40 mg IV push 3. Initiate dopamine infusion at 5 mcg/kg/min 4. Obtain blood sample for arterial blood gases
ANS : 2 The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema (Option 2). (Option 1) Digoxin is a positive inotropic drug (improves contractility) used in long-term treatment of heart failure. (Option 3) Dopamine, a positive inotropic drug, is used as a short-term treatment for ADHF; however, it does not resolve the fluid overload affecting oxygenation. (Option 4) Drawing arterial blood gases is appropriate in the setting of ADHF, but it is not the priority in this situation.
The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first? 1. Administer oxygen 2. Assess the client's breath sounds 3 Initiate cardiac monitoring 4. Insert a peripheral IV catheter
ANS : 2 Therefore, the nurse should first assess the client's breath sounds (Option 2). Rales or "crackles" may be auscultated in the lungs as a result of pulmonary congestion. (Option 1) The client's current respiratory status (ie, breath sounds, oxygen saturation) must be evaluated prior to giving oxygen. Oxygen saturation should be assessed upon admission and every 4-6 hours based on hospital protocol; oxygen is subsequently administered based on client needs. (Option 3) It is appropriate for this client to have continuous cardiac monitoring that can alert staff to life-threatening rhythms (eg, ventricular tachycardia) if they occur. However, the client's respiratory status should be assessed first. (Option 4) This client will require IV administration of diuretics, such as furosemide, to reduce excess fluid volume and preload. A peripheral IV catheter should be placed, but assessment of the client's current status takes priority.
A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client's lungs 2. Check the client's capillary refill 3. Measure the client's blood pressure 4. Review the client's electrocardiogram (ECG)
ANS : 3 Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity.
A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1. Ask the client how long the leg has been tender and warm 2. Assess the electrocardiogram (ECG) for any ectopic beats 3. Check vital signs including pulse oximetry 4. Complete neurovascular assessment on lower extremities
ANS : 4 The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. (Options 1, 2, and 3) These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation that the client is currently experiencing.
The nurse is planning care for a patient with acute myocardial infarction. What goals should the nurse use to guide this patient's care? (Select all that apply) 1. Relieve chest pain 2. Prevent complications 3. Reduce blood viscosity 4. Decrease cardiac workload 5. Reduce myocardial damage
1,2,4,5 Immediate treatment goals for the patient with an acute myocardial infarction are to reduce chest pain, myocardial damage, decrease cardiac workload, and prevent complication. Blood viscosity is not implicated in the development of an acute MI, but plays a role in peripheral vascular resistance.
A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. administer the morphine. 2. obtain a 12-lead ECG. 3. obtain the blood work. 4. prescribe the chest radiograph.
1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
A middle-aged client being admitted to the hospital has a history of hypertension and informs the nurse that his father died from a heart attack at age 60. The client reports having "indigestion." The nurse connects the client to a cardiac monitor, which reveals eight premature ventricular contractions (PVCs) per minute. The nurse should next: 1. call the healthcare provider (HCP). 2. start an IV line. 3. obtain a portable chest radiograph. 4. draw blood for laboratory studies.
2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the HCP , obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately
2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used. 1. Obtain a history of which drugs the client has used recently. 2. Administer the prescribed dose of morphine. 3. Position electrodes on the chest. 4. Take vital signs.
3,4,2,1. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram (ECG). 3. Have the client sit down immediately. 4. Assess the client's vital signs.
3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive cough.
3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.
Which is an expected outcome for a client on the 2nd day of hospitalization after a myocardial infarction (MI)? The client: 1. continues to have severe chest pain. 2. can identify risk factors for MI. 3. participates in a cardiac rehabilitation walking program. 4. can perform personal self-care activities without pain
4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first? 1. Monitor daily weights and urine output. 2. Limit visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand
4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.
ANS : 1 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.
Which symptom should the nurse teach the client with unstable angina to report immediately to the healthcare provider (HCP)? 1. a change in the pattern of the chest pain 2. pain during sexual activity 3. pain during an argument 4. pain during or after a physical activity.
1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.
ANS : 1,2,4,5 1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.
The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)? 1. Nausea and vomiting 2. New S3 heart sound 3. Occasional unifocal premature ventricular contractions (PVCs) 4. Temperature of 100.4 F (38 C)
ANS : 2 The new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the HCP. (Option 1) Clients may experience nausea and vomiting during an MI resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. This finding is not as high a priority as the S3 heart sound. (Option 3) Dysrhythmias are a common complication after an MI. Occasional PVCs are not significant, but the nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit. (Option 4) An increase in temperature following a MI is usually due to a systemic inflammatory process caused by myocardial cell death. The elevation may last as long as a week. This finding is not as significant as the S3 heart sound.
A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action? 1. Attach defibrillator pads to the client's chest 2. Check the lipid profile laboratory results 3. Obtain a 12-lead electrocardiogram (ECG) 4. Prepare to administer a heparin drip
ANS : 3 nitial interventions in emergency management of chest pain are as follows: Assess airway, breathing, and circulation (ABCs) Position client upright unless contraindicated Apply oxygen, if the client is hypoxic Obtain baseline vital signs, including oxygen saturation Auscultate heart and lung sounds Obtain a 12-lead electrocardiogram (ECG) Insert 2-3 large-bore intravenous catheters Assess pain using the PQRST method Medicate for pain as prescribed (eg, nitroglycerin) Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor) Obtain baseline blood work (eg, cardiac markers, serum electrolytes) Obtain portable chest x-ray Assess for contraindications to antiplatelet and anticoagulant therapy Administer aspirin unless contraindicated (Option 1) The defibrillator may be used if the 12-lead electrocardiogram (ECG) or cardiac monitoring shows a lethal and shockable rhythm, such as ventricular fibrillation; however, the 12-lead electrocardiogram (ECG) is priority. (Option 2) Elevated cholesterol (lipids) are indicative of long-term lifestyle behaviors and eating habits; a fasting lipid panel needs to be checked within 24 to 48 hours in all clients with presenting coronary artery disease, but this is not an emergency. (Option 4) Anticoagulation with heparin is indicated if the client's pain is determined to be due to acute coronary syndrome. There are many other causes of chest pain that do not require anticoagulation or may be contraindicated (eg, aortic dissection).
A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? 1. Give scheduled dose of metoprolol 50 mg orally 2. Instruct client to cough forcefully 3. Place client in reverse Trendelenburg position 4. Prepare to administer atropine 0.5 mg intravenous (IV) push
ANS : 4 Clients with symptomatic bradycardia should be treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine should be considered. (Option 1) Metoprolol is a beta blocker and would further reduce the heart rate. The nurse should not administer this medication and instead notify the health care provider. (Option 2) A forceful cough may cause a vasovagal reaction and further reduce the heart rate. (Option 3) The Trendelenburg position, not the reverse Trendelenburg position, is used with clients with hypotension.
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. The nurse should first: 1. increase the IV infusion rate to 150 mL/h. 2. notify the healthcare provider (HCP). 3. increase the oxygen concentration to 4 L/min. 4. administer a prescribed analgesic.
2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and 778 usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."
ANS : 2 The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat. 1. According to the American Heart Association, the client should not eat more than three (3) eggs a week, especially the egg yolk. 3. The client should drink low-fat milk, not whole milk. 4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, low-fat diet.
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client? 1. Decreasing sodium intake 2. Decreasing stress levels at work and home 3. Increasing activity level 4. Taking blood pressure medications as prescribed
ANS : 4 The priority teaching topic for this client is taking blood pressure medications as prescribed. A major problem with long-term management of hypertension is poor adherence to the treatment plan. (Options 1, 2, and 3) Decreasing sodium intake and stress levels, plus increasing activity level, are all helpful in managing hypertension. The client should be doing all these, and the teaching topics need to be reinforced. However, they are a lower priority than taking the blood pressure medications as prescribed.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.
2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation
3. Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously
ANS : 2,3 1. Morphine should be administered intravenously, not intramuscularly. 2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain. 4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in the semi-Fowler's position. 5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcutaneously.
