CH 38
After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea The client with percutaneous coronary angioplasty who has a dose of heparin scheduled The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction
A. Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate; the client with dyspnea should be seen first.
A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." "Angina is just a temporary interruption of blood flow to my heart." "I need to tell my wife I've had a heart attack." "Because this was temporary, I will not need to take any medications for my heart."
A. Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, anti-anginals, or antihypertensives.
When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? (Select all that apply.) Morphine sulfate Oxygen Nitroglycerin Naloxone Acetaminophen Verapamil (Calan, Isoptin)
A.B.C. used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.
The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (Select all that apply.) Truncal obesity Hypercholesterolemia Elevated homocysteine levels Glucose intolerance Client taking losartan (Cozaar)
A.B.D.E. A large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndr
A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? Administers oxygen therapy Obtains the client's description of the chest discomfort Provides pain relief medication Remains calm and stays with the client
B. A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A 1-inch backup of blood in the IV tubing Facial drooping Partial thromboplastin time (PTT) 68 seconds Report of chest pressure during dye injection
B. During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding. A 1-inch backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? Urine output of 1500 mL on the preceding day Crackles in the lung fields Pedal edema Expectoration of yellow sputum
B. Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.
A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? Temperature 98.2° F Chest tube drainage 175 mL last hour Serum potassium 3.9 mEq/L Incisional pain 6 on a scale of 0 to 10
B. Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL/hr to the surgeon. Although hypothermia is a common problem after surgery, a temperature of 98.2° F is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Incisional pain of 6 on a scale of 0 to 10 is expected immediately after major surgery; the nurse should administer prescribed analgesics
Prompt pain management with myocardial infarction is essential for which reason? The discomfort will increase client anxiety and reduce coping. Pain relief improves oxygen supply and decreases oxygen demand. Relief of pain indicates that the MI is resolving. Pain medication should not be used until a definitive diagnosis has been established.
B. The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.
The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? Client with dyspnea on exertion when ambulating to the bathroom Client with third-degree heart block on the monitor Client with normal sinus rhythm and PR interval of 0.28 second Client who refuses to take heparin or nitroglycerin
B. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.
he nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? Inferior wall Anterior wall Lateral wall Posterior wall
B. Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure. The client with an inferior wall MI is more likely to develop right ventricular heart failure. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.
Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) Premenopausal Increasing age Family history Abdominal obesity Breast cancer
B.C.D. Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.
Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) Sharp, inspiratory chest pain Dyspnea Dizziness Extreme fatigue Anorexia
B.C.D. Many women who experience an MI present with dyspnea, light-headedness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.
The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4° F
B.C.E. The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.
An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? No action is required; low blood pressure is normal for older adults. No action is required for postsurgical CABG clients. Assess pulmonary artery wedge pressure (PAWP). Give ordered loop diuretics.
C. Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.
The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? Assess coping skills. Assess for postoperative pain at the client's incision site. Monitor for dysrhythmias. Monitor mental status
C. Dysrhythmias are the leading cause of prehospital death; the nurse should monitor the client's heart rhythm. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.
A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? "This way you will not need to have a leg incision." "The surgeon prefers this approach because it is easier." "These arteries remain open longer." "The surgeon has chosen this approach because of your age."
C. Mammary arteries remain patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? The need to increase activities slowly at home Planning and participating in a walking program Placing a chair in the shower for independent hygiene Consultation with social worker for disability planning
C. Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning; it consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.
An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia
C. The LPN/LVN scope of practice includes administration of medications to stable clients. Third-degree heart block is characterized by a very low heart rate and usually by required pacemaker insertion; the skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability; he will need medications and monitoring beyond the scope of practice of the LPN/LVN.
The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? Reduce abdominal fat. Avoid stress. Do not smoke or chew tobacco. Avoid alcoholic beverages.
C. Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.
During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? "You are right. Work on your diet then." "You must find someplace to walk." "Walk around the edge of your apartment complex." "Where might you be able to walk?"
D. Asking the client where he or she might be able to walk calls for cooperation and participation from the client; increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.
To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase Homocysteine and C-reactive protein Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol CK-MB and troponin
D. CK-MB and troponin are the cardiac markers used to determine whether MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.
Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? "I will be awake during this procedure." "I will have a balloon in my artery to widen it." "I must lie still after the procedure." "My angina will be gone for good."
D. Reocclusion is possible after PTCA. The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.
The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? Chest pain brought on by exertion or stress Substernal chest discomfort occurring at rest Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids
D. Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.
The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? Pulse 60 beats/min and regular Urinary frequency Incisional discomfort Respiratory rate 28 breaths/min
D. Tachypnea and tachycardia reflect activity intolerance; activity should be terminated. Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Pain with activity after surgery is anticipated; pain medication should be available.
