Cardiovascular System - Diagnostic Testing / Intervention

Cardiac Enzymes

Creatine kinase-MB - Peaks around 24 hr after onset of chest pain. Levels no longer evident after 3 days. Troponin I or T - Any positive value indicates damage to cardiac tissue and should be reported. X Troponin I - Levels no longer evident after 7 days. Troponin T - Levels no longer evident after 14 to 21 days. Myoglobin - Earliest marker of injury to cardiac or skeletal muscle. Levels no longer evident after 24 hr.

Hemodynamic monitoring

Heart failure generally results in increased central venous pressure (CVP), increased pulmonary wedge pressure (PAWP), increased pulmonary artery pressure (PAP), and decreased cardiac output (CO). Mixed venous oxygen saturation (SvO2) is directly related to cardiac output. A drop in SvO2 indicates worsening cardiac function.

Nursing Care - Cardiac catheterization

Monitor Vital signs every 15 min until stable, then every hour Serial ECG, continuous cardiac monitoring Location, precipitating factors, severity, quality, and duration of pain Hourly urine output - greater than 30 mL/hr indicates renal perfusion Laboratory data (cardiac enzymes, electrolytes, ABGs) Administer oxygen (2 to 4 L/min). Obtain and maintain IV access. Promote energy conservation (cluster nursing interventions).

Postprocedure

Nursing Actions The client is monitored by 12-lead ECG and his blood pressure is checked frequently until he is stable. The provider reviews findings with client.

Plethysmography

Plethysmography is used to determine the variations of blood passing through an artery, thus identifying abnormal arterial flow in the affected limb. Blood pressure cuffs are attached to the client's upper extremities and a lower extremity and attached to the plethysmograph machine. Variations in peripheral pulses between the upper and lower extremity are recorded. A decrease in pulse pressure of the lower extremity indicates a possible blockage in the leg.

Stress test

Stress test - Also known as exercise electrocardiography. Client tolerance of activity is tested using a treadmill, bicycle, or medication to evaluate response to increased heart rate. The cardiac muscle is exercised by the client walking on a treadmill. This provides information regarding the workload of the heart. Once the client's heart rate reaches a certain rate, the test is discontinued. Clients can become too tired, may be disabled or physically challenged, and be unable to finish the test. The provider can prescribe the test to be done as a pharmacological stress test.

Thallium scan

Thallium scan - Assesses for ischemia or necrosis. Radioisotopes cannot reach areas with decreased or absent perfusion, and the areas appear as "cold spots." Nursing Actions Instruct the client to avoid smoking and consuming caffeinated beverages 4 hr prior to the procedure. These can affect the test.

Varicose veins - sclerotherapy

Varicose veins - sclerotherapy ■ A sclerosing irritating chemical solution is injected into the varicose vein to produce localized inflammation, which will, close the lumen of the vessel over time. For larger vessels, an incision and drainage of the trapped blood in a sclerosed vein may need to be performed 2 to 3 weeks after the injection. Pressure dressings are applied for approximately 1 week after each procedure to keep the vessel free of blood. ■ Client Education ☐ Instruct the client to wear elastic stockings for prescribed time. Mild analgesics such as acetaminophen (Tylenol) can be taken for discomfort.

APPLICATION EXERCISES KEy 1. A. INCORRECT: Administering pain mediation is important, but it is not the priority nursing intervention. B. INCORRECT: Ensuring a warm environment is important, but it is not the priority nursing intervention. C. CORRECT: Using the ABC priority-setting framework, the greatest risk to the client is inadequate circulatory volume. The priority nursing intervention is to administer IV fluids. D. INCORRECT: Initiating a 12-lead ECG is important, but it is not the priority nursing intervention. NCLEX® Connection: Physiological Adaptations, Medical Emergencies CORRECT: Pulses distal to the graft site should be monitored to detect possible occlusion of the graft. 2. A. B. CORRECT: Pain below the graft site can be an indication of graft occlusion or rupture. C. INCORRECT: The head of the bed should be maintained at less than 45° to prevent flexion of the graft. D. CORRECT: Antiplatelet agents and anticoagulants are prescribed to prevent thrombus formation. E. INCORRECT: An hourly urine output of 60 mL/hr is an expected finding. 3. A. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures INCORRECT: An aneurysm ruptures as a result of thickening in the intima of the artery and a lack of elasticity in the vessel wall, which is usually under pressure due to hypertension. B. INCORRECT: A bruit is objective data, which indicates the presence of an aneurysm, not the cause of rupture. C. INCORRECT: Abdominal distention may occur when an aneurysm ruptures, but it is not the cause of the rupture. D. CORRECT: Hypertension increases pressure within the arterial walls, resulting in rupture. NCLEX® Connection: Physiological Adaptations, Pathophysiology RN Adult MedicAl SuRgicAl NuRSiNg RN Adult MedicAl SuRgicAl NuRSiNg 441 CHAPTER 38 ANeuRySMS 4. A. INCORRECT: Decreased urine output is an expected finding with occlusion of a graft of the aorta. B. INCORRECT: Decreased or absent pedal pulse is an expected finding with occlusion of a graft of the aorta. C. CORRECT: Abdominal distention is an expected finding with occlusion of a graft of the aorta. D. INCORRECT: Pallor or cyanosis of the extremities is an expected finding with occlusion of a graft of the aorta. NCLEX® Connection: Physiological Adaptations, Pathophysiology 5. A. CORRECT: Cough is a manifestation of a thoracic aortic aneurysm. B. CORRECT: Shortness of breath is a manifestation of a thoracic aortic aneurysm. C. INCORRECT: Report of severe back pain is a clinical finding of thoracic aortic aneurysm. D. INCORRECT: Diaphoresis is a clinical finding of dissecting aortic aneurysm. E. CORRECT: Difficulty swallowing is a manifestation of a thoracic aortic aneurysm. NCLEX® Connection: Physiological Adaptations, Pathophysiology 6. Using the ATI Active Learning Template: Systems Disorder A. Risk Factors ● Male sex ● Atherosclerosis ● Uncontrolled hypertension ● Tobacco use ● Age-related changes to the artery (loss of elastin, thickening of the intima, progressive fibrosis) B. Diagnostic Procedures ● X-rays ● CT scans ● Ultrasonography C. Nursing Interventions ● Take vital signs every 15 min until stable. Then, every hour, monitoring for increased blood pressure. ● Assess pain (onset, quality, duration, severity). ● Assess temperature, circulation, and range of motion of extremities. ● Monitor cardiac rhythm continuously. ● Monitor hemodynamic findings. ● Monitor ABGs, Sa02, electrolytes, CBC laboratory findings. ● Monitor hourly urine output. ● Administer oxygen as prescribed. ● Obtain and maintain IV access. ● Administer medications as prescribed.

1. A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia. 2. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb 3. A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood flow to the heart is stopped. 4. A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure. CHAPTER 30 iNvASive cARdiovASculAR PRoceduReS APPLICATION EXERCISES CHAPTER 30 iNvASive cARdiovASculAR PRoceduReS 5. A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg 6. A nurse is developing the plan of care for a client who is returning to the unit following angioplasty. What should be included in the plan of care? Use the ATI Active Learning Template: Therapeutic Procedure to complete this item to include the following sections: A. Nursing Actions: Describe five postprocedure nursing actions. B. Potential Complications: ● Describe at least two. ● Describe at least two actions related to each of these complications.

APPLICATION EXERCISES 1. A nurse is caring for a client who has pericarditis. Which of the following expected findings should the nurse anticipate? A. Petechiae B. Murmur C. Rash D. Friction rub 2. Which of the following clients has the greatest risk of acquiring rheumatic endocarditis? A. An older adult who has chronic obstructive pulmonary disease B. A child who has an upper respiratory streptococcal infection C. A middle-age adult who has lupus erythematosus D. A young adult who is at 24 weeks of gestation 3. A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should be reported to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L 4. A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. For which of the following conditions is the client at risk? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis RN Adult MedicAl SuRgicAl NuRSiNg RN Adult MedicAl SuRgicAl NuRSiNg 391 CHAPTER 34 iNFlAMMAtoRy diSoRdeRS 5. A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture 6. A nurse is reviewing discharge teaching with a client who has myocarditis. What should the nurse include in the teaching? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Care After Discharge: ● Identify at least two referral facilities and the services they can provide. ● Describe at least four actions the client should take when at home.

APPLICATION EXERCISES KEy 1. A. B. INCORRECT: A murmur is an expected finding in a client who has myocarditis and endocarditis. C. INCORRECT: Rash is an expected finding in a client who has rheumatic endocarditis. D. CORRECT: A friction rub can be heard during auscultation of a client who has pericarditis. INCORRECT: Petechiae are expected findings in a client who has endocarditis. 2. A. NCLEX® Connection: Physiological Adaptations, Pathophysiology INCORRECT: An older adult who has chronic obstructive pulmonary disease is at risk, but this client is not the highest risk. B. CORRECT: A child who has an upper respiratory due to streptococcal bacteria is at highest risk for developing rheumatic endocarditis. Approximately 50% of clients who have rheumatic fever develop rheumatic endocarditis. C. INCORRECT: A middle-age adult who has lupus erythematosus is at risk, but this client is not the highest risk. D. INCORRECT: A young adult who is at 24 weeks of gestation is at risk, but this client is not the highest risk. 3. A. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention CORRECT: Long-term NSAID therapy can lower platelets. This finding is outside the expected reference range and should be reported to the provider. B. INCORRECT: Serum glucose is not affected by long-term NSAID therapy. This finding is within the expected reference range. C. INCORRECT: Kidney function, which is monitored by serum creatinine level, is affected by long-term NSAID therapy. This finding is within the expected reference range. D. INCORRECT:Liver function, which is monitored by the ALT level, is affected by long-term NSAID therapy. This finding is within the expected reference range. NCLEX® Connection: Physiological Adaptations, Pathophysiology RN Adult MedicAl SuRgicAl NuRSiNg RN Adult MedicAl SuRgicAl NuRSiNg 393 4. A. CHAPTER 34 iNFlAMMAtoRy diSoRdeRS CORRECT: Splinter hemorrhages in nail beds and a report of fever are findings associated with 5. A. NCLEX® Connection: Physiological Adaptations, illness Management INCORRECT: Arterial blood gases are used to monitor the respiratory status of a client who has suspected rheumatic endocarditis, but they do not confirm the diagnosis. infective endocarditis. B. INCORRECT: A client who has pericarditis would report chest pain. C. INCORRECT: A client who has myocarditis would report a rapid heart rate. D. INCORRECT: A client who has rheumatic endocarditis would report joint pain. B. INCORRECT: Serum albumin monitors the nutrition status of a client who has a suspected inflammatory disorder, but it does not confirm the diagnosis. C. INCORRECT: Liver enzymes monitor a client's response to antibiotic therapy, which is used to treat rheumatic endocarditis, but they do not confirm the diagnosis. D. CORRECT: A throat culture can reveal the presence of streptococcus, which is the leading cause of rheumatic endocarditis. NCLEX® Connection: Reduction of Risk Potential, Laboratory values 6. Using the ATI Active Learning Template: Systems Disorder A. Care After Discharge ● Referral facilities ◯ Home health - postoperative care ◯ Pharmaceutical services - intravenous antibiotic therapy, provision of supplies and medications ◯ Rehabilitation services - assistance with monitoring and increasing activity level ● Discharge activities by the client ◯ Rest as needed. ◯ Wash hands to prevent infection. ◯ Avoid crowded areas to reduce the risk of infection. ◯ Maintain good oral hygiene to prevent infection. ◯ Take medications as prescribed. ◯ Administer and manage IV antibiotics. ◯ Participate in a smoking cessation program.

APPLICATION EXERCISES 1. A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz of nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz of beer daily E. Getting a massage once a week 2. A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first? A. Administer acetaminophen for headache. B. Provide teaching in regard to the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication. 3. A nurse is providing discharge teaching for a client who has a prescription for furosemide (Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take this medication? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime 4. A nurse is caring for a client who has a new diagnosis of hypertension and a new prescription for spironolactone (Aldactone) 25 mg/day. Which of the following statements by the client indicates a need for further teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate or rhythm." C. "I should use a salt substitute that is low in potassium." D. "I will continue to take this medication even if I am feeling better." RN Adult MedicAl SuRgicAl NuRSiNg RN Adult MedicAl SuRgicAl NuRSiNg 417 CHAPTER 36 HyPeRteNSioN 5. A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider? A. Takes psyllium hydrophilic muccilloid (Metamucil) daily B. Drinks skim milk daily C. Takes metoprolol (Lopressor) daily D. Drinks grapefruit juice daily 6. A student nurse is preparing a post-conference presentation on hypertension. What should be included in the presentation? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disorder/Disease Process: Describe hypertension to include essential, secondary, and prehypertension. B. Risk Factors: Describe at least four risk factors for secondary hypertension. C. Objective and Subjective Data: ● Describe at least three subjective data. ● Describe the objective data stages of hypertension.

APPLICATION EXERCISES KEy 1. A. C. INCORRECT: Engaging in regular exercise, such as walking, lowers the risk of developing hypertension. D. CORRECT: Consuming more than 24 oz of beer per day can contribute to weight gain, which increases the risk for hypertension. E. INCORRECT: Stress management activities, such as a massage, lowers the risk of hypertension. NCLEX® Connection: Health Promotion and Maintenance, High Risk Behaviors 2. A. C. CORRECT: The greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which can be life-threatening and should be lowered as soon as possible. Obtaining IV access will permit administration of an IV hypertensive, which will act more rapidly than by the oral route. D. INCORRECT: Calling social services is an appropriate action, but it is not the first action. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration INCORRECT: Consuming low-fat beverages and foods lowers the risk for developing hypertension. B. CORRECT: Popcorn at a movie theater contains a large quantify of sodium and fat, which increases the risk for hypertension. INCORRECT: Administering acetaminophen is an appropriate action, but it is not the first action. B. INCORRECT: Providing teaching regarding medication administration is an appropriate action, but it is not the first action. 3. A. CORRECT: The client should take furosemide, a diuretic, in the morning so that the peak action and duration of the medication occurs during waking hours. 4. A. NCLEX® Connection: Physiological Adaptations, Hemodynamics CORRECT: Potatoes and bananas are high in potassium, and spironolactone is a potassium-sparing diuretic. Consuming these foods can lead to hyperkalemia. B. INCORRECT: Taking furosemide, a diuretic, at this time increases the likelihood of interruption of the client's sleep due to the need to urinate. C. INCORRECT: Taking furosemide, a diuretic, at this time increases the likelihood of interruption of the client's sleep due to the need to urinate. D. INCORRECT: Taking furosemide, a diuretic, at this time increases the likelihood of interruption of the client's sleep due to the need to urinate. B. INCORRECT: The client should report any changes in heart rate or rhythm. C. INCORRECT: Using salt substitutes that are low in potassium prevents hyperkalemia. D. INCORRECT: The client should be instructed to continue taking her medication even if she is symptom-free. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration RN Adult MedicAl SuRgicAl NuRSiNg RN Adult MedicAl SuRgicAl NuRSiNg 419 CHAPTER 36 HyPeRteNSioN 5. A. INCORRECT: Adverse effects of Metamucil do not include hypoglycemia. This does not need to be reported to the provider. B. INCORRECT: Skim milk will increase blood glucose levels and lower cholesterol. This does not need to be reported to the provider. C. CORRECT: Lopressor can mask the effects of hypoglycemia in clients with diabetes mellitus. This should be reported to the provider. D. INCORRECT: Grapefruit juice will increase blood glucose levels. This does not need to be reported to the provider. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/ Side Effects/interactions 6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ● Hypertension is when systolic blood pressure is at or above 140 mm Hg or diastolic blood pressure is at or above 90 mm Hg. ● Essential, or primary hypertension, has no known cause. ● Secondary hypertension is caused by certain diseases, such as kidney disorders, or as an adverse effect of a medication. Treatment occurs by removing the cause. ● Prehypertension is when a client has a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 Hg. B. Risk Factors for Secondary Hypertension: kidney disease, Cushing's disease, primary aldosteronism (caused by hypertension and hypokalemia), pheochromocytoma (excessive catecholamine release), brain tumors, encephalitis, and medications such as estrogen, steroids, and sympathomimetics C. Objective and Subjective Data ● Subjective Data: few or no symptoms; can include headaches, particularly in the morning; dizziness, fainting, retinal changes, visual disturbances, nocturia. ● Objective Data ◯ Obtain blood pressure readings in both arms with the client sitting and standing: Prehypertension - systolic 120 to 139 mm Hg, diastolic 80 to 89 mm Hg Stage I - systolic 140 to 159 mm Hg, diastolic 90 to 99 mm Hg Stage II - systolic greater than or equal to 160 mm Hg, diastolic greater than or equal to 100 mm Hg

APPLICATION EXERCISES 1. A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min. 2. A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin 3. A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C. "Aspirin dissolves clots that are forming in your coronary arteries." D. "Aspirin relieves headaches that are caused by other medications." 4. A nurse is instructing a client who has angina about a new prescription for metoprolol tartrate (Lopressor). Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rate is less than 60." CHAPTER 31 ANgiNA ANd MyocARdiAl iNFARctioN CHAPTER 31 ANgiNA ANd MyocARdiAl iNFARctioN 5. A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules 6. A nurse is teaching a client who has new diagnosis of angina about a new prescription for nitroglycerin (Nitrostat). Which of the following should be included in the teaching? Use the ATI Active Learning Template: Medication and the ATI Pharmacology Review Module to complete this item to include the following sections: A. Therapeutic Uses B. Side/Adverse Effects: ● Describe two. ● Describe at least one teaching point for each side/adverse effect. C. Medication/Food Interactions: Describe two. D. Nursing Administration: Describe how the client should be instructed to take the medication in response to chest pain.

APPLICATION EXERCISES KEy 1. A. CORRECT: Angina can be relieved by rest and nitroglycerin. B. INCORRECT: The pain associated with an MI usually lasts longer than 30 min and requires opioid analgesics for relief. C. INCORRECT: There is no specific type of activity that causes an MI. It may occur following rest. D. INCORRECT: The pain of angina usually occurs for 15 min or less. NCLEX® Connection: Physiological Adaptations, Hemodynamics CHAPTER 31 ANgiNA ANd MyocARdiAl iNFARctioN 2. A. B. INCORRECT: Troponin I levels are no longer evident after 7 days. C. CORRECT: The Troponin T level will still be evident 14 to 21 days following an MI. D. INCORRECT: Myoglobin levels are no longer evident after 24 hr. INCORRECT: The creatinine kinase MB levels are no longer evident after 3 days. 3. A. NCLEX® Connection: Reduction of Risk Potential, Laboratory values CORRECT: Aspirin decreases platelet aggregation that can cause a myocardial infarction. B. INCORRECT: One aspirin a day is not sufficient to alleviate ischemic pain. C. INCORRECT: Aspirin does not dissolve clots. D. INCORRECT: Other medications can cause headaches, but one aspirin per day is not administered as an analgesic. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 4. A. C. INCORRECT: Ringing in the ears is not an adverse effect of the medication. Dry mouth and mucous membranes can occur. D. CORRECT: The client is advised to notify the provider if bradycardia (pulse rate less than 60) occurs. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention INCORRECT: Lopressor is administered orally, not sublingual. B. INCORRECT: Lopressor does not affect bleeding or clotting time. A CBC and blood glucose should be monitored periodically. CHAPTER 31 ANgiNA ANd MyocARdiAl iNFARctioN 5. A. INCORRECT: Diet modification is an important recommended lifestyle change, but there is another action that is more important. B. INCORRECT: The use of relaxation exercises is an important recommended lifestyle change, but there is another action that is more important. C. CORRECT: According to the airway, breathing, and circulation (ABC) priority-setting framework, adequate oxygenation is the priority. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries. Therefore, smoking cessation should be the first recommended lifestyle change. D. INCORRECT: Taking omega-3 capsules is an important recommended lifestyle change, but there is another action that is more important. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 6. Using the ATI Active Learning Template: Medication A. Therapeutic Uses ● Treatment of acute angina attack B. Side/Adverse Effects ● Headache ◯ Take aspirin or acetaminophen to relieve pain. ◯ Notify the provider if headache persists. ● Orthostatic hypotension ◯ Sit or lie down if experiencing dizziness or faintness. ◯ Avoid sudden position changes, and rise slowly. ● Reflex tachycardia ◯ Monitor pulse and BP. ● Tolerance ◯ Take lowest dose needed to achieve effect. C. Medication/Food Interactions ● Alcohol can have a hypotensive effect. ● Other beta-blocker medications, calcium channel blockers, and diuretics can contribute to hypotensive effects. ● Male clients should not take sildenafil if prescribed nitroglycerin. D. Nursing Administration ● Stop activity and rest. Place tablet under tongue to dissolve. If pain is unrelieved in 5 min, call 911 or ask to be driven to the emergency department. Take two more doses at 5-min intervals.

APPLICATION EXERCISES 1. A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? A. Edema around the client's ankles and feet B. Ulceration around the client's medial malleoli C. Scaling eczema of the client's lower legs with stasis dermatitis D. Pallor on elevation of the client's limbs and rubor when his limbs are dependent 2. A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? A. With the affected limb hanging from the bed B. With the affected limb elevated on pillows C. With the head of the bed raised D. In a side-lying, recumbent position 3. A nurse is teaching a client who has a new prescription for clopidogrel (Plavix). Which of the following should be included in the teaching? (Select all that apply.) A. Effects may not be apparent for several weeks. B. Monitor for the presence of black, tarry stools. C. Instruct the client to use an electric razor. D. Schedule a weekly PT test. E. Advise the client about food sources containing vitamin K. 4. A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? A. "I will remind your provider that you are already receiving heparin." B. "Laboratory findings indicated that two anticoagulants were needed." C. "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis." CHAPTER 35 PeRiPHeRAl vASculAR diSeASeS CHAPTER 35 PeRiPHeRAl vASculAR diSeASeS 5. A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A. massage both legs firmly with lotion prior to applying the stockings. B. apply the stockings in the morning upon awakening and before getting out of bed. C. roll the stockings down to the knees if they will not stay up on the thighs. D. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest. 6. A nurse is developing a poster presentation on peripheral arterial disease (PAD) for a community health fair. What content should the nurse include on the poster? Use ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disease Process B. Risk Factors: Describe at least six. C. Objective Data: Describe at least six findings. D. Client Education: Describe at least two actions by the client related to proper positioning and two actions related to promoting vasodilation.

APPLICATION EXERCISES KEy 1. A. INCORRECT: Edema around the ankles and feet is an expected finding in a client who has venous stasis. B. INCORRECT: Ulceration around the medial malleoli is an expected finding in a client who has venous stasis. C. INCORRECT: Scaling eczema of the lower legs with stasis dermatitis is an expected finding in a client who has venous stasis. D. CORRECT: In a client who has chronic PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered. NCLEX® Connection: Physiological Adaptations, Pathophysiology 2. A. CORRECT: The client will prefer sleeping with the affected extremity in a dependent position because this relieves pain. B. INCORRECT: This sleeping position does not promote circulation in the lower extremity. C. INCORRECT: This sleeping position does not promote circulation in the lower extremity. D. INCORRECT: This sleeping position does not promote circulation in the lower extremity. NCLEX® Connection: Physiological Adaptations, Pathophysiology 3. A. CORRECT: Therapeutic benefits may not occur for several weeks when taking Plavix. B. CORRECT: Evidence of GI bleeding, such as abdominal pain, coffee-ground emesis, or black, tarry stools should be monitored and reported to the provider. C. INCORRECT: Bleeding precautions are required for a client taking anticoagulants, not antiplatelet medications. D. INCORRECT: PT and INR levels are monitored regularly in a client taking warfarin (Coumadin). E. INCORRECT: A client who is taking warfarin (Coumadin) should be advised about food sources containing vitamin K. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention 4. A. INCORRECT: Warfarin is prescribed for 3 to 4 days before discontinuing IV heparin. B. INCORRECT: IV heparin is monitored to achieve adequate therapeutic levels in treating a DVT. C. CORRECT: Warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. Therefore, it takes 3 to 4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur. D. INCORRECT: Heparin and warfarin are both effective in treating DVTs. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration CHAPTER 35 PeRiPHeRAl vASculAR diSeASeS 5. A. INCORRECT: Massaging the affected area can dislodge a clot and cause embolism. B. CORRECT: Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time. C. INCORRECT: Rolling stockings down can restrict circulation and cause edema. D. INCORRECT: Stockings should remain in place throughout the day and are removed before going to bed to provide continuous venous support. If the stockings are removed, such as for a bath or shower, then the legs should be elevated before the stockings are reapplied. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disease Process: PAD is inadequate blood flow of the lower extremities due to atherosclerosis. The intima and media of the arteries becomes thickened, and plaques may form on the walls of the arteries, making them rough and fragile. The arteries progressively stiffen and the lumen narrows, decreasing blood supply to tissues and increasing resistance to blood flow. It is classified as either an inflow or outflow type of PAD. B. Risk Factors ● Hypertension ● Hyperlipidemia ● Diabetes mellitus C. Objective Data ● Bruits over femoral and aortic arteries ● Decreased capillary refill of toes (greater than 3 seconds) ● Decreased or nonpalpable pulses ● Loss of hair on the lower extremities ● Dry, scaly mottled skin D. Client Education ● Actions related to positioning ◯ Avoid crossing the legs. ◯ Avoid wearing restrictive garments. ◯ Keep legs elevated to reduce swelling but not above the level of the heart. ● Cigarette smoking ● Obesity ● Sedentary lifestyle ● Familial predisposition ● Age ● Thick toenails ● Cold, cyanotic extremity ● Pallor of extremity with elevation ● Dependent rubor ● Muscle atrophy ● Ulcers and possible gangrene of toes ● Actions to promote vasodilation ◯ Maintain a warm environment. ◯ Wear insulated socks. ◯ Avoid applying direct heat to the extremity. ◯ Avoid exposure to cold. ◯ Avoid stress, caffeine, and nicotine.

Ultrasound

An ultrasound (also called cardiac ultrasound or echocardiogram), 2-D (two-dimensional) or 3-D (three-dimensional) is used to measure systolic and diastolic function of the heart. Left ventricular ejection fraction (LVEF): The volume of blood pumped from the left ventricle into the arteries upon each beat. Normal is 55% to 70%. Right ventricular ejection fraction (RVEF): The volume of blood pumped from the right ventricle to the lungs upon each beat. Normal is 45% to 60%.

Cardiac catheterization A coronary angiogram, also called a cardiac catheterization, is an invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage.

Angiography involves the insertion of a catheter into a femoral (sometimes a brachial) vessel and threading it into the right or left side of the heart. Coronary artery narrowing and occlusions are identified by the injection of contrast media under fluoroscopy. Nursing Actions Ensure the client understands the procedure prior to signing informed consent. Ensure that the client remains NPO 8 hr prior to procedure. Assess that the client and family understand the procedure. Assess for iodine/shellfish allergy (contrast media).

PAD - PAD results from atherosclerosis that usually occurs in the arteries of the lower extremities and is characterized by inadequate flow of blood. Progressive stiffening of the arteries and narrowing of the lumen decreases the blood supply to affected tissues and increases resistance to blood flow. ● Atherosclerosis is actually a type of arteriosclerosis, which means "hardening of the arteries" and alludes to the loss of elasticity of arteries over time due to thickening of their walls. ● PAD is classified as inflow (distal aorta and iliac arteries) or outflow (femoral, popliteal, and tibial arteries) and may range from mild to severe. Tissue damage occurs below the arterial obstruction.

Arteriography Arteriography of the lower extremities involves arterial injection of contrast medium to visualize areas of decreased arterial flow on an x-ray. It is usually done only to determine isolated areas of occlusion that can be treated during the procedure with percutaneous transluminal angioplasty and possible stent placement. Nursing Actions Observe for bleeding and hemorrhage. Palpate pedal pulses to identify possible occlusions.

Cardiac Markers Human B-type natriuretic peptides (hBNP): Elevated in heart failure.

In clients who have dyspnea, elevated hBNP confirms a diagnosis of heart failure rather than a problem originating in the respiratory system. hBNP levels direct the aggressiveness of treatment interventions. A level below 100 pg/mL indicates no heart failure. Levels between 100 to 300 pg/mL suggest heart failure is present. A level above 300 pg/mL indicates mild heart failure. A level above 600 pg/mL indicates moderate heart failure. A level above 900 pg/mL indicates severe heart failure.

Ventricular assist devices (VADs) provide left, right, or biventricular support for failing hearts for a longer term (usually months).

Indication Extension of cardiopulmonary bypass Failure to wean Postcardiotomy cardiogenic shock Bridge to recovery or cardiac transplantation Patients with New York Heart Association Classification IV who have failed medical therapy Many patients will die or choose to terminate device, causing death. Contraindications: BSA less than manufacturer's limit (1.3 m2); Renal or Liver failure unrelated to a cardiac event; Co-morbidities that would limit life expectancy to less than 3 years. Nursing Management: Circulatory Assist Devices Nursing care of the patient with a VAD is similar to that of the patient with an IABP. Patients are observed for bleeding, cardiac tamponade, ventricular failure, infection, dysrhythmias, renal failure, hemolysis, and thromboembolism. A patient with a VAD may be mobile and require an activity plan. Ideally, patients with CADs will recover. However, many patients die, or the decision to terminate the device is made and death follows. Both the patient and caregiver require psychologic support.

Intraprocedure

Nursing Actions Apply a 12-lead ECG to monitor the client's heart rate during the test.

Preprocedure

Preprocedure Nursing Actions Ensure that a signed informed consent form is obtained. Explain to the client that he will be walking on a treadmill, and comfortable shoes and clothing are recommended. If a pharmacological stress test is prescribed, a medication such as adenosine (Adenocard) or dobutamine (Dobutrex) is given to stress the heart instead of walking on the treadmill. Instruct the client to fast 2 to 4 hr before the procedure according to facility policy and to avoid tobacco, alcohol, and caffeine before the test.

Segmental systolic blood pressure measurements

Segmental systolic blood pressure measurements A Doppler probe is used to take various blood pressure measurements (thigh, calf, ankle, brachial) for comparison. In the absence of peripheral arterial disease, pressures in the lower extremities are higher than those of the upper extremities. With arterial disease, the pressures in the thigh, calf, and ankle are lower.

Surgical procedures for PAD

Surgical procedures for PAD ■ Percutaneous transluminal angioplasty Invasive intra-arterial procedure using a balloon and stent to open and help maintain the patency of the vessel. It is used for candidates who are not suitable for surgery or in cases where amputation is inevitable. ■ Laser-assisted angioplasty ☐ Laser-assisted angioplasty is an invasive procedure in which a laser probe is advanced througha cannula to the site of stenosis. The laser is used to vaporize atherosclerotic plaque and open the artery. ■ Nursing Actions The priority action is to observe for bleeding at the puncture site. Monitor the client's vital signs, peripheral pulses, and capillary refill. If prescribed, keep the client on bed rest with his limb straight for 6 to 8 hr before ambulation. Anticoagulant therapy is used during the operative procedure, followed by antiplatelet therapy for 1 to 3 months.

Transesophageal echocardiography (TEE)

Transesophageal echocardiography (TEE) uses a transducer placed in the esophagus behind the heart to obtain a detailed view of cardiac structures. The nurse prepares the client for a TEE in the same manner as for an upper endoscopy.

● Surgical Interventions Varicose veins - vein stripping ■ Vein stripping is the removal of large varicose veins that cannot be treated with less-invasive procedures.

■ Nursing Actions Preoperatively Assist the provider with vein marking. Evaluate the client's pulses as baseline for postoperative comparison. Postoperatively Maintain elastic bandages on the legs. Monitor groin and leg for bleeding through the elastic bandages. Monitor extremity for edema, warmth, color, and pulses. Elevate legs above the level of the heart. Encourage the client to engage in range-of-motion exercises of the legs. Instruct the client to elevate the legs when sitting, and avoid dangling them over the side of the bed. Client Education ☐ Emphasize the importance of wearing elastic stockings after bandage removal.