Chapter 38: Care of Patients with Acute Coronary Syndromes

39. Which essential preoperative teaching would the nurse provide to a client scheduled for CABG surgery using the traditional procedure? Select all that apply. A. There will be a sternal incision. B. Coughing will be avoided to keep stress off of the sternal incision. C. There will as many as three chest tubes in place after the surgery. D. An indwelling urinary catheter will be in place to drain urine. E. You will be on bedrest for up to 48 hours after the surgery. F. An endotracheal tube will prevent talking immediately after surgery.

A, C, D, F For the traditional surgical procedure, explain that the client will have a sternal incision and possibly a large leg incision also; one, two, or three chest tubes; an indwelling urinary catheter; pacemaker wires; and invasive hemodynamic monitoring. An endotracheal tube will be connected to a ventilator during surgery. The endotracheal tube is removed as soon as the client is awake and stable. Tell the client and family that the client will not be able to talk while the endotracheal tube is in place. Two hours after extubation (removal of the endotracheal tube), clients should be dangled at the bedside as tolerated and turned side to side. Within 4 to 8 hours after extubation, help clients out of bed into a chair. By the first day after surgery, they should be out of bed in a chair and ambulating 25 to 100 feet three times a day as tolerated. Encourage the client to splint, cough, turn, and deep breathe to expectorate secretions.

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding . DIF: Applying/Application REF: 782KEY: Coronary artery disease| intra-arterial blood pressure monitoring| equipment safety| vital signs MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive. DIF: Applying/Application REF: 792KEY: Coronary artery disease| sexuality| anxiety| therapeutic communication MSC: Integrated Process: CaringNOT: Client Needs Category: Psychosocial Integrity

21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the clients integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working. DIF: Applying/Application REF: 784KEY: Inotropic agents| adverse effects| medication safetyMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

20. A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

ANS: B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern. DIF: Applying/Application REF: 792KEY: Home safety| referrals| coronary artery bypass graftMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such. DIF: Understanding/Comprehension REF: 779KEY: Coronary artery disease| thrombolytic agents| patient educationMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

17. A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable. DIF: Analyzing/Analysis REF: 785KEY: Coronary artery disease| critical rescue| medical emergencies| hypersensitivities| allergic reaction MSC: Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. DIF: Applying/Application REF: 780KEY: Coronary artery disease| activity intolerance| vital signs| nursing assessment MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications. DIF: Applying/Application REF: 780KEY: Coronary artery disease| critical rescue| medical emergenciesMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

23. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

ANS: C The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM). DIF: Remembering/Knowledge REF: 785KEY: Coronary artery disease| Core Measures| The Joint CommissionMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal. DIF: Remembering/Knowledge REF: 783KEY: Coronary artery disease| critical rescue| nursing assessmentMSC: Integrated Process: Nursing Process: AnalysisNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

12. The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. DIF: Applying/Application REF: 787KEY: Coronary artery disease| infection control| hand hygieneMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. DIF: Applying/Application REF: 781KEY: Coronary artery disease| hemodynamic monitoring| fluid and electrolyte imbalance MSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

37. Which clients are potential candidates for coronary artery bypass graft (CABG) surgery? Select all that apply. A. Client with angina and greater than 50% occlusion of the left main coronary artery that cannot be stented B. Client with unstable angina with moderate one-vessel disease appropriate for stenting C. Client with valvular disease D. Client with coronary vessels unsuitable for percutaneous coronary intervention (PCI) E. Client with acute myocardial infarction (MI) that is responding to medical therapy F. Client with ischemia or impending MI after angiography or PCI

A, C, D, F Candidates for CABG surgery are clients who have: angina with greater than 50% occlusion of the left main coronary artery that cannot be stented; unstable angina with severe two-vessel disease, moderate three-vessel disease, or small-vessel disease in which stents could not be introduced; ischemia with heart failure; acute MI with cardiogenic shock; signs of ischemia or impending MI after angiography or percutaneous coronary intervention; valvular disease; and coronary vessels unsuitable for percutaneous coronary intervention (PCI).

A nurse is auscultating heart sounds on a client and detects an S4 sound. The nurse should identify that this sound represents which of the following heart conditions? A. Atrial gallop B. Ventricular gallop C. Closure of the mitral valve D. Closure of pulmonic valve

Correct Answer: A. Atrial gallop The nurse should identify that an S4 sound represents an atrial gallop, which is caused by decreased compliance of either or both ventricles. This can be heard in clients who have hypertension, anemia, ventricular hypertrophy, myocardial infarction, aortic or pulmonic stenosis, and pulmonary emboli. Incorrect Answers: B. An S3 represents a ventricular gallop caused by a rush of blood into a ventricle that is very compliant. This can be an expected finding in clients younger than 35 years. It can be an early indication of heart failure in clients over the age of 35 and is considered pathognmic for heart failure in this age bracket. C. Closure of the mitral valve is represented by the S1 heart sound. D. Closure of the pulmonic valve is represented by the S2 heart sound. Vital Concept: A nurse who is auscultating hearts should be able to identify S1 and S2 as expected heart sounds, and recognize unexpected heart sounds such as S3 and S4, referred to as gallop sounds. It is important for the nurse to understand what causes these sounds to occur and the individual heart valves associated with them.

A nurse is caring for a 6-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority? A. Auscultating the rate and characteristics of the child's heart sounds B. Using a pain-rating tool to determine the severity of the joint pain C. Checking the degree of edema D. Assessing the client's erythematous rash

Correct Answer: A. Auscultating the rate and characteristics of the child's heart sounds Using the airway, breathing, circulation approach to client care, the nurse's priority assessment should be auscultating the client's heart rate, and heart sounds. Rheumatic fever is an inflammatory disease that begins with strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications. Incorrect Answers: B. Pain in one or more joints is characteristic of rheumatic fever. However, because joint pain is not life-threatening, and since there are usually no permanent sequelae to the joint involvement in rheumatic fever, this is not the priority assessment the nurse should make. C. Polyarthritis is a manifestation of rheumatic fever and is caused by edema, effusions of the joints, and inflammation. However, this is not the priority assessment the nurse should make. D. The nurse should assess the client's rash. However, this is not the priority assessment the nurse should make. Vital Concept: The priority assessment for a child who has an acute rheumatic fever is to conduct a cardiac assessment to identify tachycardia and murmurs, which can be life-threatening. The child can also exhibit findings of congestive heart failure (CHF) and have cardiomegaly. Pericarditis can occur and carditis is the only finding that leads to permanent damage.

A nurse advises a client with congestive heart failure and a new prescription for furosemide to take the medication in the morning. Why is this the recommendation? A. Additional nighttime accumulation of fluid can be excreted. B. Taking the drug in the daytime will prevent disturbance of sleep. C. Electrolyte balance is maintained with morning administration of the medication. D. The drug is more rapidly absorbed when the client is awake.

Correct Answer: B. Taking the drug in the daytime will prevent disturbance of sleep. Treatment for congestive heart failure often includes loop diuretic therapy with furosemide or bumetanide to reduce peripheral and pulmonary edema by reducing sodium and water retention by the kidney. Furosemide and bumetanide may result in hypokalemia from potassium wasting. Other medications used for treatment of heart failure include angiotensin-converting enzyme inhibitors (ACEIs), including Lisinopril, enalapril, and captopril; angiotensin II receptor blockers (ARBs) such as valsartan and losartan; beta-blockers, including metoprolol or carvedilol; and digoxin, which is a cardiac inotrope that increases the contractility of the heart and reduces heart rate. Advise clients to take furosemide early in the day to avoid the disturbance in sleep caused by nighttime urination. Incorrect Answers: A. The time of administration does not affect the mechanism or efficacy of the drug. C. The time of administration does not affect electrolyte balance. D. The time of administration does not affect absorption of the drug. Vital Concept: Heart failure results in volume overload coupled with inadequate perfusion. Loop diuretics, including furosemide (Lasix) and bumetanide (Bumex) interfere with reabsorption of sodium and water by the kidney, resulting in diuresis. This results in reduction of preload and improves symptoms in clients with heart failure.

A nurse is caring for a client with pulmonary embolism. The client is hypotensive and dyspneic. Which of the following client outcomes is the priority in this client? A. The client will remain free of hemorrhage and abnormal bleeding related to medications B. The client will have increased cardiac output C. The urinary output will be above 20 mLs per hour D. The client will be free of left-sided heart failure

Correct Answer: B. The client will have increased cardiac output "The client will have increased cardiac output" is the priority expected client outcome when a client with a pulmonary embolus. Although the nurse should insure that the client will also be free of hemorrhage and abnormal bleeding related to medications such as anticoagulants that prevent future clotting, the priorities are: airway, breathing, and then circulation (which includes cardiac output). Other expected outcomes for clients affected with pulmonary emboli are the maintenance of urinary output of 30 mLs or more per hour, and the absence of cor pulmonale, or right-sided heart failure. Incorrect Answers: A. This is important for the client taking anticoagulant medications, but the nurse must first ensure that the client's heart continues beating. C. The client should have at least 30 mL of urine output per hour. D. The client may be at risk of right-sided heart failure, not left-sided. Vital Concept: A pulmonary embolism is a sudden blockage in an artery that supplies the lung. It usually occurs after a deep vein thrombosis breaks loose and travels through the bloodstream to the lung. Pulmonary embolism can cause permanent damage to the affected lung; low oxygen levels in the blood; and damage to other organs due to impaired gas exchange. A large PE can result in hemodynamic collapse and death. In a hypotensive client, restoration of adequate cardiac output is the goal of treatment. Anticoagulants and/or thrombolytic medications are prescribed to break up clots and to prevent additional clots from forming.

A nurse is reviewing the laboratory results of a middle-aged adult client who has Stage 4 chronic kidney disease. Which of the following findings should the nurse expect? A. Blood urea nitrogen (BUN) 15 milligrams per deciliter (mg/dL) B. Glomerular filtration rate (GFR) 20 milliliters per minute (mL/min) C. Creatinine 1.1 milligrams per deciliter (mg/dL) D. Potassium 5.0 millequivalents per liter (mEq/L)

Correct Answer: B. Glomerular filtration rate (GFR) 20 milliliters per minute (mL/min) The GFR is a measurement of the amount of blood the nephron is able to filter in 1 min and is an indication of renal function. The expected reference range for the GFR in a middle-aged adult is between 93 and 107 mL/min. A client who has stage 4 chronic kidney disease can have a GFR in the range of 15 to 29 mL/min. Incorrect Answers: A. Urea nitrogen is a byproduct of protein metabolism and is excreted in the urine. The BUN level is directly correlated to renal functioning. The expected reference range for an adult client is 10 to 20 mg/dL. Elevated BUN levels can indicate a variety of conditions such as shock, dehydration, heart failure, gastrointestinal bleeding, and kidney disease. The nurse should expect the BUN level of a client who is in stage 4 chronic kidney disease to be up to 20 times greater than the expected reference range. C. Creatinine is a result of the metabolism of creatine phosphate, an enzyme needed for skeletal muscle contraction. It is excreted in the urine and levels are correlated to the functioning of the kidneys. The expected reference range for creatinine increases with age from a low of 0.1 to 0.4 mg/dL in an infant to 0.5 to 1.3 mg/dL in the older adult client. Elevated creatinine levels can indicate dehydration or a renal disorder such as chronic kidney disease. A client who has stage 4 chronic kidney disease can have a creatinine level greater than 30 mg/dL. D. Due to the decreased ability of the kidneys to excrete fluids and electrolytes, the client who has stage 4 chronic kidney disease is at risk for developing hyperkalemia. This occurs when the urine output is less than 500 mL/day. The expected reference range for potassium is 3.5 to 5 mEq/L. A client in stage 4 chronic kidney disease will have a potassium level greater than 5 mEq/L. Vital Concept: Chronic kidney disease is a progressive and irreversible disorder resulting in decreasing function of the kidneys. There are 5 stages of chronic kidney disease which are based on the ability of the kidney's nephrons to filter blood, referred to as the glomerular filtration rate (GFR). At stage 1, the client can have a GFR of 90 mL/min or more but by the time the client reaches the 5th level, or end stage kidney disease, the GFR is less than 15 mL/min. Other indicators of renal function include the creatinine and the blood urea nitrogen (BUN) levels. The nurse should monitor a variety of laboratory results for a client who has chronic kidney disease including sodium, potassium, calcium, phosphorus, magnesium, hemoglobin, hematocrit, serum osmolality, and arterial blood gases in addition to those mentioned above.

A nurse is preparing to administer mannitol 1 g/kg of 20% solution IV. Which of the following conditions should be considered a contraindication for using this type of medication? A. Cerebral edema B. Oliguria C. Heart failure D. Increased intraocular pressure

Correct Answer: C. Heart failure Mannitol is an osmotic diuretic that is most commonly used to reduce increased intracranial pressure by moving intracellular fluid into the extracellular space. Mannitol is not used for clients with heart failure because its effects can ultimately cause fluid overload in the intravascular space when the medication pulls excess fluid out of edematous tissues. Incorrect Answers: A. Mannitol is designed to treat cerebral edema; this is not a contraindication. B. Oliguria is not necessarily affected by mannitol and would not be a contraindication in this case. D. Increased intraocular pressure is not a contraindication for mannitol. Vital Concept: Mannitol is an osmotic diuretic used to treat elevated intracranial and intraocular pressure. It pulls fluid from parenchymal cells that is then excreted in the urine. It also reduces blood viscosity and improves cerebral perfusion. Adverse effects include pulmonary edema, acute renal failure, dehydration, and electrolyte disturbances. It is contraindicated in pulmonary edema or congestion and should be avoided in clients with heart failure.

The Registered Nurse has been assigned the following clients. Which client should the nurse assess as a priority? A. A client who has shortness of breath on exertion and a history of COPD. B. A client who has generalized shortness of breath and heart failure. C. A client is with dyspnea who has asthma and whose breath sounds are diminished in the upper lobes and absent in the lower lobes. D. A client with Shortness of breath on exertion who has recently been diagnosed with bronchitis.

Correct Answer: C. A client is with dyspnea who has asthma and whose breath sounds are diminished in the upper lobes and absent in the lower lobes. A client with asthma who has diminishing or absent breath sounds has severely limited air movement. This is an ominous sign and should be treated rapidly period this is the priority. Incorrect Answers: A, B, D. The client who has COPD is expected to have shortness of breath on exertion. This is an expected finding an is not the priority. The client who has generalized shortness of breath and heart failure has expected, but significant findings. While these symptoms should not be ignored and should be treated promptly, this is not the priority client. Shortness of breath on exertion is an expected finding with bronchitis and this is not the priority. Vital Concept: As a nurse, it will be critical that you begin to identify expected and unexpected assessment findings. You will be expected to group these findings together and prioritize them from most important to least important to address. In doing so, this will allow you to provide better case care to your clients In a more organized and timely fashion.

A client complains of feeling "lightheaded" after radiofrequency catheter ablation. His cardiac monitor reveals dissociation of P waves and QRS complexes as shown below. Which of the following is the most appropriate first nursing intervention? A. Call the rapid response team for cardioversion. B. Notify the healthcare provider and prepare to administer atropine. C. Notify the cardiologist and prepare for transcutaneous or transvenous pacing. D. Document the rhythm and assessment in the client's chart and monitor for further changes.

Correct Answer: C. Notify the cardiologist and prepare for transcutaneous or transvenous pacing. Whatever the cause, the nurse should recognize a complete heart block. The rhythm shown is third-degree heart block, which is complete dissociation of atrial and ventricular arrhythmia caused by a failure of the conduction system. This can occur after radiofrequency ablation, which is ablation of electrical pathways that cause tachyarrhythmia. Third-degree heart block can result in pre-syncope (lightheadedness), dizziness, fainting, confusion, hypotension, bradycardia, or heart failure. The ECG will demonstrate a regular rate and rhythm, but the P waves and Q waves have no relationship to one another. Third-degree heart block requires temporary or permanent pacing and is a life-threatening condition. Incorrect Answers: A. Cardioversion is indicated for the treatment of stable tachyarrhythmia. B. Pacing is necessary for Mobitz type II second-degree heart block and third-degree heart block because both conditions involve disorders of the conduction system that are not responsive to atropine. Atropine reduces the effects of the vagus nerve on the heart and can be effective in symptomatic bradycardia and lesser degrees of heart block. D. Third-degree heart block must be treated immediately because it is a life-threatening arrhythmia. Vital Concept: Complete heart block, or third-degree atrioventricular block, refers to complete AV dissociation, in which no atrial impulses are conducted to the ventricles. Atria and ventricles contract independently. The ventricles contract in an escape rhythm, with the rate dependent upon the site of the block. The atrial rate is usually sinus at 60-100/minute. AV block results in reduction of cardiac output, with ischemia, heart failure, and syncope. A transcutaneous or transvenous pacemaker should be placed emergently.

A nurse is planning to advise a client with heart failure who has a new prescription for digoxin. Which of the following signs of toxicity should the nurse include when advising the client? A. Increased pedal edema B. Redness on upper chest and neck C. Vision changes, including appearance of yellow haloes around some objects D. Dry cough

Correct Answer: C. Vision changes, including appearance of yellow haloes around some objects Digoxin is a cardiac glycoside. It increases the contractility of the heart (positive inotrope) and reduces the heart rate (negative chronotrope) in individuals with congestive heart failure. These actions increase the cardiac output of the heart. It is also used for the treatment of atrial fibrillation. Therapeutic levels of digoxin range from 0.5 to 2 ng/mL. The medication is contraindicated in second- and third-degree heart block and should not be given to clients with a pulse <60/min. A client with digoxin toxicity may complain of nausea, vomiting, and/or yellow-green haloes around objects. The client should also be advised that use of a calcium supplement may lead to increased risk of toxicity, including arrhythmias. The antidote for digoxin toxicity is Digibind. A high-potassium diet is recommended for individuals who take digoxin. Incorrect Answers: A. Digoxin is used to treat congestive heart failure. One of the signs of congestive heart failure is peripheral edema. B. This describes red man syndrome, which is a hypersensitivity reaction to vancomycin. D. A dry, persistent cough is a side effect of angiotensin-converting enzyme inhibitors (ACEIs). Vital Concept: Digoxin is a medication used to treat congestive heart failure. It is a cardiac inotrope, which increases the contractility of the heart. Levels must be monitored carefully, since toxicity occurs at serum concentrations above the therapeutic range of 0.5 to 2 ng/mL. Signs of toxicity include arrhythmias, nausea, vomiting, and visual changes, including an appearance of yellow/yellow-green haloes around objects.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client, which of the following statements is the priority to report to the provider? A. "I had a mastectomy and chemotherapy." B. "I recently completed a course of prednisone for acute bronchitis." C. "I am seeing a dermatologist for a skin rash." D. "I am currently taking furosemide for congestive heart failure."

Correct Answer: D. "I am currently taking furosemide for congestive heart failure." Diuretics, such as furosemide, are contraindicated for use with lithium due to the risk of toxicity. Diuretics excrete sodium chloride along with water. In place of sodium, the body tends to hold onto lithium, which is also a salt, leading to an increased risk for toxicity. This is the greatest risk for the client and is the highest priority to report to the provider. Incorrect Answers: A. Contraindications to taking lithium include a history of cardiovascular or renal disease. Lithium can be used cautiously in clients who have thyroid disease or diabetes. The nurse should inform the provider of the client's history because chemotherapy can cause leukopenia, which is also an adverse effect of lithium. However, another finding is the priority. B. The nurse should notify the provider about the current medications the client is taking. Prednisone can cause elevated blood glucose levels, which is also an adverse effect of lithium. However, since the client is no longer taking the prednisone, there is another priority finding that the nurse should report. C. Lithium is associated with a number of dermatologic adverse effects, such as pruritis, folliculitis, alopecia, and acne. The nurse should notify the provider of the client's rash, so it can be noted and the client can be monitored for changes to the rash or increased pruritis. However, there is another finding that is the priority for the nurse to report. Vital Concept: Lithium is a medication that has a narrow therapeutic range and has a number of contraindications and interactions. When obtaining information from a client such as a history of illnesses and medications, the nurse should listen carefully to client responses. The nurse should take a thorough medical history and prioritize that information. Findings should be shared with the provider so safe and effective client care can be delivered.

The nurse is preparing to administer one unit of whole blood. Which of the following describes the most life-threatening complication associated with blood transfusion? A. A chill rigor reaction B. Hepatitis A C. A febrile nonhemolytic reaction D. Transfusion-related circulatory overload

Correct Answer: D. Transfusion-related circulatory overload One of the most serious and life-threatening complications associated with blood transfusions is transfusion-related circulatory overload. The client may develop signs of heart failure and dyspnea. This type of reaction is responsible for approximately 20 percent of transfusion-related deaths. Incorrect Answers: A. A chill rigor reaction may be a more common reaction to blood transfusion, but it is not the most life-threatening. B. Transmission of hepatitis B and C occur through the blood. Hepatitis A is transmitted through the fecal-oral route. C. A febrile non-hemolytic reaction may be a more common reaction to blood transfusion, but it is not the most life-threatening. Vital Concept: The most common complications of transfusion include febrile nonhemolytic reactions . and chill-rigor reactions. Serious complications are less common but have high mortality rates. They include transfusion-associated circulatory overload; transfusion-related acute lung injury; and acute hemolytic reaction due to ABO incompatibility. If the nurse recognizes symptoms of a blood transfusion reaction, with the exception of localized urticaria and itching, but including chills, rigor, fever, dyspnea, light-headedness, and flank pain, the transfusion should be stopped immediately. The IV line should be kept open with normal saline. The remainder of the blood product and samples of the client's blood should be sent to the blood bank for investigation.

A nurse is caring for a client with a closed head injury who has had an increase in blood pressure from 168/92 to 254/120. What is this client's current pulse pressure? A. 28 B. 76 C. 86 D. 134

Correct Answer: D. 134 The current pulse pressure for this client is 134. Pulse pressures are calculated by subtracting the diastolic blood pressure from the systolic blood pressure (254 - 120 = 134). A wide and widening pulse pressure is a sign of increased intracranial pressure, which often occurs after a head injury. Vital Concept: Pulse pressure refers to the difference between the systolic and diastolic blood pressure, measured in millimeters of mercury (mmHg). The pulse pressure represents the force that the heart generates each time it contracts. Normal pulse pressure ranges from 30 mmHg to 50 mmHg. Low pulse pressure is associated with reduced cardiac output and may be seen in clients with heart failure. The pulse pressure measurement increases or widens with aging, due to high blood pressure or atherosclerosis. Other causes of increased pulse pressure include iron deficiency anemia and hyperthyroidism.

A nurse is assessing a client with myocardial ischemia. Which of the following may cause this condition? (Select all that apply) A. Helicobacter pylori B. Hyperthyroidism C. Anemia D. Dysrhythmia E. Vasodilation F. Prolonged INR

Correct Answers: B. Hyperthyroidism C. Anemia D. Dysrhythmia Coronary perfusion refers to supply of blood to the heart. Myocardial ischemia occurs when the myocardial cells receive an inadequate supply of oxygenated blood to meet metabolic demands. Perfusion of myocardial cells is affected by a variety of factors such as arterial blood flow, myocardial workload, and blood oxygen content. The presence of atherosclerosis, thrombosis, and vasospasm reduce the flow of blood to the heart. Myocardial workload is increased by increased metabolic demands from hyperthyroidism, rapid heart rate from dysrhythmia, and increased preload or afterload from the heart itself. Dysrhythmias can also result in ineffective pumping action by the heart. Anemia reduces the red blood cell count, which in turn reduces the oxygen content of blood carried to the myocardium. Incorrect Answers: A. Helicobacter pylori is a bacteria that effects the stomach and most commonly the small intestine. It does not effect the heart. E. Vasodilation is not associated with ACS. Actually when nitroglycerin is given to a patient experiencing chest pain it decreases the work of the heart and causes vasodilation of the coronary arteries, which improves coronary blood flow. F. Prolonged INR is not associated with ACS and may actually help improve patient outcomes by improving coronary blood flow. Vital Concept: Acute coronary syndrome (ACS) refers to a ischemic chest pain caused by atherosclerotic disease and ranging clinically from unstable angina, non ST segment elevation myocardial infarction and ST segment elevation myocardial infarction. It is important to identify and treat ACS as rapidly as possible to avoid damage to the myocardium. Assessment of chest pain should focus on the history of the pain, the client's cardiovascular risk factor profile, and any previous history of chest pain or atherosclerotic disease.

The nurse is teaching a client with polycythemia vera about potential complications from the disease. Which manifestations should the nurse include in the client's teaching plan? (Select all that apply.) A. Hearing loss B. Visual disturbances C. Headache D. Gout E. Weight loss

Correct Answers: B. Visual disturbances C. Headache D. Gout Polycythemia vera, a condition in which too many red blood cells are produced in the blood serum, can lead to an increase in the hematocrit with hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure and increased clotting time or symptoms of an increased uric acid level such as painful, swollen joints, usually in the big toe. Incorrect Answers: A. and E. Hearing loss and weight loss are not manifestations associated with this condition. Vital Concept: Polycythemia vera is characterized by uncontrolled, rapid proliferation or hyperplasia of all bone marrow cells. The increased red blood cell mass makes the blood abnormally viscous and inhibits blood flow to the microcirculation. This results in decreased blood flow and increased risk of iintravascular thrombosis. A client with polycythemia vera may complain of a feeling of fullness in the head or ears, tinnitus, headache, dizziness, vertigo, epistaxis, night sweats, epigastric pain, joint pain, vision disturbances (scotomas, double vision, and blurred vision), pruritus, spontaneous bruising, and abdominal fullness. Physical findings on assessment include congestion of the conjunctiva, retina, and retinal veins; hypertension; ruddy cyanosis; facial plethora; ecchymosis; and hepatosplenomegaly

9. When would the nurse be sure to hold a beta blocker drug and notify the health care provider? A. When a client states he or she woke up with a headache B. When a client's respiratory rate is 26 breaths/min on room air C. When a client is scheduled for a chest x-ray D. When a client's heart rate is less than 50 beats/min and SBP is less than 100 mm Hg

D The nurse would not give beta blockers if the pulse rate was below 50 beats/min or the systolic BP was below 100 mm Hg. He or she would first check with the health care provider. The beta- blocking agent could lead to persistent bradycardia or further reduction of systolic BP, leading to poor peripheral and coronary perfusion.

14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

✔ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. DIF: Analyzing/Analysis REF: 788KEY: Coronary artery disease| coronary artery bypass graft| collaborationMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

✔ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart. DIF: Applying/Application REF: 789KEY: Coronary artery bypass graft| critical rescue| chest tubes| cardiovascular system MSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

✔ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate. DIF: Understanding/Comprehension REF: 772KEY: Coronary artery disease| lipid-reducing agents| supplements| patient education MSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Health Promotion and Maintenance

16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

✔ANS: B The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed. DIF: Remembering/Knowledge REF: 777KEY: Coronary artery disease| Core Measures| The Joint CommissionMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

✔ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings. DIF: Applying/Application REF: 781KEY: Coronary artery disease| hemodynamic monitoring| equipment safetyMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

✔ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the clients anxiety. DIF: Applying/Application REF: 787KEY: Coronary artery disease| preoperative nursing| psychosocial response| anxiety| coping| therapeutic communication MSC: Integrated Process: CaringNOT: Client Needs Category: Psychosocial Integrity

A nurse is performing an ECG on a client who is being evaluated for chest pain. The nurse notes that the client has elevated ST segments > 2 mm in leads II, III, and aVF. Which of the following is the most likely explanation for these findings? A. Acute MI B. Hypocalcemia C. Hyperkalemia D. Cardiac tamponade

✔Correct Answer: A. Acute MI An ECG is a non-invasive method of detecting changes in heart rhythm and conduction abnormalities. The nurse should be familiar with the appearance of a normal ECG and with ECG abnormalities associated with common conditions. Elevated ST segments in two contiguous leads in a client with symptoms of acute coronary syndrome are most likely to be acute myocardial infarction. Incorrect Answers: B. The client's ECG results indicate a myocardial infarction, not hypocalcemia. A long QT interval is characteristic of hypocalcemia. C. The client's ECG results indicate a myocardial infarction, not hyperkalemia. Hyperkalemia is characterized by peaked T waves. D. The client's ECG results indicate a myocardial infarction, not cardiac tamponade. Vital Concept: ST elevation myocardial infarction (STEMI) is characterized by clinical symptoms consistent with acute coronary syndrome in addition to persistent ST elevation in 2 or more contiguous leads. The ST elevation must be ≥ 2.5 mm ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm ST elevation in leads V2-3 in men over 40 years. In women, ST elevation of ≥ 1.5 mm is required in V2-3 and ≥ 1 mm ST elevation in other leads. Each small square is equal to 1 mm. See image below.

The nurse is caring for a client with acute coronary syndrome. Which of the following are the most common findings associated with this condition? (Select all that apply) A. Chest pain at rest B. ST segment changes on ECG C. Cardiac markers outside expected range D. Presence of Q wave on ECG E. T wave inversion on ECG F. Eupnea occurs

✔Correct Answers: A. Chest pain at rest B. ST segment changes on ECG C. Cardiac markers outside expected range E. T wave inversion on ECG Acute coronary syndrome arises out of blockage or diminished blood flow in the coronary arteries. It is usually characterized as partial blockage where blood flow is diminished. The causes include artery spasm, vessel obstruction, inflammation of the coronary artery, and erosion of plaque in the artery. Symptoms include chest pain at rest that radiates to the neck and arm, dyspnea or shortness of breath, nausea, vomiting, tachycardia, and hypotension. The ECG (electrocardiogram) result includes ST segment changes and T wave inversion; cardiac markers such as troponin may be either elevated or within normal range. Acute coronary syndrome is treated with aspirin, clopidogrel, nitroglycerine, and analgesics (morphine). Eupnea refers to normal breathing, whereas dyspnea refers to difficulty in breathing. Vital Concept: When a client with possible acute coronary syndrome arrives seeking medical care, the nurse will obtain blood for laboratory studies and a 12-lead ECG. Medications used in treatment of ACS include oxygen, aspirin, nitrates, analgesics, beta-blockers, ACE inhibitors or ARBs; antiplatelet agents, and fibrinolytic drugs.

A client with myocardial ischemia is scheduled for treatment with bile acid sequestrant. Which of the following drugs will be prescribed? (Select all that apply) A. Pravastatin B. Cholestyramine C. Atorvastatin D. Colestipol E. Fenofibrate

✔Correct Answers: B. Cholestyramine D. Colestipol Myocardial ischemia is a condition that arises due to insufficient blood supply to the muscle of the heart. The myocardium is the muscle of the heart that provides the pumping action of the heart. The blood flow to the myocardium may be partially or fully obstructed causing ischemia and death of muscle cells. Factors such as buildup of plaque and obesity can cause this. Bile acid sequestrant is a class of drug that lowers LDL (low density lipoproteins) by binding bile acids in the intestine, reducing their reabsorption and reducing cholesterol production in the liver. Cholestyramine (Questran), colestipol (Colestid), and colesevelam (Welchol) are examples of drugs that belong to this class. Constipation and bloating are the major side effects that can occur when taking these drugs. Vital Concept: Atherosclerosis is a process that begins with damage to the endothelium of the arteries, followed by deposit of lipids, including LDL cholesterol. Formation of plaques narrow arteries. Stable plaques can cause angina. Rupture of a plaque in the coronary arteries causes acute coronary syndrome, with unstable angina or myocardial infarction.

Values Mark A client reports to the nurse that his anginal pain is worse after activity. To help the client understand this, the nurse explains that angina pectoris is a sign of which of the following? A. Mitral insufficiency B. Myocardial ischemia C. Myocardial infarction D. Coronary embolism

✔Correct answer B . Myocardial ischemia Angina pectoris is chest pain caused by reduced perfusion to cardiac muscle with subsequent hypoxemia. Incorrect Answers: A. This refers to an incompetent mitral valve. While it could indirectly relate to angina, that would not be the direct cause. C. Cell death does not occur in angina. Cell death occurs in myocardial infarction after complete blockage of flow to the cardiac muscle. D. Coronary thrombosis, not embolism, is the usual mechanism of occlusion or narrowing of the coronary arteries in acute coronary syndrome. Vital Concept: Acute coronary syndrome refers to a range of conditions associated with sudden reduction of blood flow to the heart. These conditions include angina, characterized by ischemic chest pain, and myocardial infarction, characterized by cell death and destruction of heart tissue. Rapid diagnosis is important to outcome in ACS. Treatment goals include improved or restored perfusion, treatment of complications and prevention of future cardiovascular events.

A nurse is providing discharge teaching for a client with a new diagnosis of angina who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the client's teaching? A. Replace tablets every month. B. If there is no relief after 1 tablet or if pain worsens after 1 tablet, contact EMS. C. Keep this medication refrigerated. D. Swallow the tablet with water or juice.

✔Correct answer B If there is no relief after 1 tablet or if pain worsens after 1 tablet, contact EMS. Sublingual nitroglycerin tablets and spray are self-administered by clients as needed, for relief of angina. Nitroglycerin dilates the coronary arteries of the heart to improve blood flow. If the client does not achieve some relief of chest pain or if chest pain worsens after one nitroglycerin tablet, EMS should be contacted. The traditional recommendation was for clients to take one nitroglycerin dose sublingually every five minutes for up to three doses before calling for emergency medical services (EMS) evaluation. This recommendation was updated in 2004 by the American College of Cardiology and the American Heart Association, after research suggested that waiting for three doses could result in significant delays in obtaining EMS assistance. The client will require evaluation with an ECG to rule out acute coronary syndrome or myocardial infarction. When using nitroglycerin tablets, the client should be sure the mouth is moist and should not swallow saliva until the tablet is dissolved. The tablet may be crushed between the teeth in cases of severe pain, but should still be absorbed sublingually. Nitroglycerin tablets should be kept in a dark glass container at all times to prevent degradation of the medication. It is inactivated by heat, light, air, and moisture, and tablets should be replaced every six months. Incorrect Answers: A. Nitroglycerin tablets should be replaced every 6 months after opening to ensure they retain potency. C. Nitroglycerin tablets are kept with the client in case of chest pain. D. Nitroglycerin should not be swallowed. The sublingual form is taken under the tongue. Vital Concept: Nitroglycerin tablets should be kept in a dark glass container at all times to prevent degradation of the medication, since nitroglycerin is inactivated by heat, light, air, and moisture. Unused tablets should be discarded and replaced every six months. The tablets should be taken sublingually. The mouth should be moist, but the client should not swallow saliva until the tablet is completely dissolved. If chest pain worsens or does not improve within five minutes after one NTG tablet, the client should call EMS.

47. Which procedure would the nurse expect to be recommended for a client with discrete, proximal, noncalcified blockage in one coronary artery? A. Minimally invasive direct coronary artery bypass (MIDCAB) B. Percutaneous coronary intervention (PCI) C. Immediate thrombolytic reperfusion therapy D. Exercise tolerance test (stress test) on a treadmill

B Clients who are most likely to benefit from PCI have single- or double-vessel disease with discrete, proximal, noncalcified lesions or clots.

36. Which procedure has shown promise for managing clients with cardiogenic shock? A. Percutaneous ventricular assistive device B. Immediate reperfusion C. Intra-aortic balloon pump D. Minimally invasive bypass surgery

B Immediate reperfusion is an invasive intervention that shows some promise for managing cardiogenic shock. The client is taken to the cardiac catheterization laboratory, and an emergency left-sided heart catheterization is performed. If the client has a treatable occlusion or occlusions, the interventional cardiologist performs a PCI in the catheterization laboratory, or the client is transferred to the operating suite for a coronary artery bypass graft (CABG).

38. Which interventions would the nurse perform to protect a client from a sternal wound infection after CABG surgery? Select all that apply. A. Shave the client's body from neck to knees. B. Instruct the client to shower with 4% chlorhexidine gluconate. C. Prepare the surgical site by clipping hair then applying chlorhexidine with isopropyl alcohol (0.5% or 2 %). D. Collect and send urine and sputum samples to the laboratory for culture and sensitivity. E. Administer IV antibiotics 1 hour prior to the surgical procedure. F. Wear gloves, a gown, and a mask while preparing the client for surgery.

B, C, E To decrease risk of a sternal wound infection, the nurse would have the client shower with 4% chlorhexidine gluconate (CHG). This decreases the number of microorganisms on the skin. Surgical sites are prepared by clipping hair and applying CHG with isopropyl alcohol (either 0.5% or 2%). In addition, IV antibiotics are administered 1 hour before the surgical procedure. Research suggests that shaving a client's skin before surgery may raise the risk of an infection; thus, shaving a client's body may not protect against infection nor would sending lab specimens or wearing protective equipment.

2. Which essential points would the nurse include when teaching a client with angina about nitroglycerin tablets? Select all that apply. A. If one tablet does not relieve the chest pain after 5 minutes, put two pills under your tongue. B. Keep your nitroglycerin pills with you at all times. C. The prescription should last about 7 to 8 months before a refill is needed. D. You can tell the tablets are active when you feel a tingling after placing one under your tongue. E. Keep the tablets in a glass, light-resistant container. F. If no immediate pain relief occurs, just wait because the drug will eventually take effect.

B, D, E Teach the client to carry NTG at all times. Keep the tablets in a glass, light-resistant container because the drug degrades quickly in light, moisture, and in plastic. The drug should be replaced every 3 to 5 months before it loses its potency or stops producing a tingling sensation when placed under the tongue. Management of chest pain at home includes: keep fresh nitroglycerin available for immediate use; at the first indication of chest discomfort, cease activity and sit or lie down; place one nitroglycerin tablet under your tongue, allowing the tablet to dissolve; wait 5 minutes for relief; if no relief results, call 911 for transportation to a health care facility; while waiting for emergency medical services (EMS), repeat the nitroglycerin and wait 5 more minutes; if there is no relief, repeat and wait 5 more minutes. Be sure to carry a medical identification card or wear a bracelet or necklace that identifies a history of heart problems.

13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

✔ANS: C For the nurses safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. DIF: Applying/Application REF: 782KEY: Standard Precautions| infection control| intra-arterial blood pressure monitoring| staff safety MSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client who has undergone angioplasty for acute myocardial infarction that penetrated the entire thickness of the heart wall. This type of cardiac injury is referred as a(n): A. Ischemic infarction B. Transmural infarction C. Subendocardial infarction D. Hypoxemia infarction

✔Correct answer B Transmural infarction A transmural infarction describes a myocardial infarction injury that penetrates the entire wall of the myocardium. This term is used to classify the type of heart attack that has occurred, as a myocardial infarction is classified according to its location and the depth of the muscle penetrated. Incorrect Answers: A. While a myocardial infarction involves an ischemic injury, this is not the term used in this situation. C. A subendocardial infarction only penetrates the inner part of the heart muscle during a heart attack, not the entire heart muscle. D. This is not a term used to classify a myocardial infarction. Vital Concept: Current terminology for acute coronary syndrome includes unstable angina (UA), non-ST elevation MI (NSTEMI), and ST elevation MI (STEMI). STEMI is usually characterized by complete occlusion of a major epicardial coronary artery, resulting in necrosis of the full thickness of the myocardium, from the endocardium through the myocardium to the epicardium.

11. The nurse would teach a client to seek treatment for symptoms of myocardial infarction (MI) immediately rather than delay, because physical changes occur in how many hours after an MI? A. 3 hours B. 6 hours C. 12 hours D. 24 hours

. B Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted region appears blue and swollen. These changes explain the need for intervention within the first 4 to 6 hours of symptom onset!

45. Which assessment would the nurse perform to help prevent harm from graft collapse after CABG surgery? A. Assess for motion and sensation in the donor extremity. B. Observe for generalized hypothermia. C. Auscultate lungs for crackles or wheezes. D. Monitor blood pressure for hypotension.

45. D The nurse would monitor for hypotension (systolic BP <90 mm Hg) which is a major problem because it may result in the collapse of the coronary graft. Decreased preload can result from hypovolemia or vasodilation. If the client is hypovolemic, it might be appropriate to increase fluid administration or administer blood. The cardiac health care provider may manage the client with volume replacement followed by vasopressor therapy to increase the BP. However, if hypotension is the result of left ventricular failure, IV inotropes (e.g., dopamine, dobutamine) might be needed.

41. How would the critical care nurse assess for postoperative bleeding in a client who just had CABG surgery? A. Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage amount over 150 mL/hr to the surgeon. B. Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amount over 50 mL/hr to the surgeon. C. Assess the sternal dressing for bleeding every 4 hours, then reinforce with sterile gauze as needed and report the approximate amount of bleeding to the surgeon. D. Assess the vein donor site every 4 hours and report the amount of serous drainage as well as pain to the surgeon.

A Bleeding after CABG surgery occurs to a limited extent in all clients. Measure mediastinal and pleural chest tube drainage at least hourly. Report drainage amounts over 150 mL/hr to the surgeon.

10. Which finding would the nurse expect when a client experiences a non-ST-segment elevation MI (NSTEMI)? A. ST depression and T-wave inversion on a 12-lead ECG B. Cardiac dysrhythmias C. Immediate elevation of troponin levels D. ST elevation in two contiguous leads on a 12-lead ECG

A Clients with NSTEMI present with ST segment and T-wave changes on a 12-lead ECG. These changes include ST depression and T-wave inversion, which indicate myocardial ischemia. Initially troponin level may be normal, but it elevates over the next 3 to 12 hours (not immediately). ST elevation in two contiguous leads on a 12-lead ECG is characteristic of STEMI.Dysrhythmias may occur with any MI and are not specific to NSTEMI.

35. Which manifestation would the nurse expect with a client labeled class I on the Killip scale for heart failure? A. Clear lung sounds and absence of S3 B. Crackles in the lower half of the lung fields and possible S3 C. Crackles more than halfway up the lung fields and frothy sputum D. Systolic blood pressure less than 90 mm Hg and oliguria

A The classic Killip system identifies four classes of heart failure based on prognosis. The class I description includes absence of crackles and S3. See Table 35.5 for descriptions of classes II, III, and IV.

5. What is the nurse's next action 5 minutes after administering a sublingual (SL) nitroglycerin tablet to a client with chest pain? A. Apply oxygen at 2 to 4 L by nasal cannula. B. Administer morphine sulfate IV push. C. Recheck pain intensity and vital signs. D. Notify the health care provider and give a chewable aspirin.

C Five minutes after administering a sublingual nitroglycerin tablet, the nurse would check the client's pain level and check his or her blood pressure

1. Which findings would the nurse expect when assessing a client with chronic stable angina? Select all that apply. A. Chest discomfort that occurs in a pa

A, B, C, E, F All of these characteristics describe chronic stable angina, except that this condition results in only slight limitation of activity (not moderate).

8. Which statements about coronary artery disease and women are accurate? Select all that apply. A. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men. B. Women have smaller coronary arteries and frequently have plaque that breaks off and travels into the small vessels to form an embolus. C. The older a woman is the more likely she is to have coronary artery disease. D. More men than women die within a year after a MI. E. Women whose parents had CAD are more susceptible to the disease. F. Many women experience atypical angina as indigestion, pain between shoulders, aching jaw, and a choking sensation.

A, B, C, E, F All of these statements are accurate except that more women than men die within a year after a myocardial infarction.

50. Which alternative therapies may be helpful in reducing a client's anxiety about progressive activity postoperatively and during rehabilitation? Select all that apply. A. Guided imagery B. Progressive muscle relaxation C. Acupuncture D. Music therapy E. Pet therapy F. Herbal remedies

A, B, D, E Additional therapies can aid in reducing the client's anxiety about progressive activity both in the immediate postoperative period and during the rehabilitation phase. Techniques such as progressive muscle relaxation, guided imagery, music therapy, pet therapy, and therapeutic touch may decrease anxiety, reduce depression, and increase adherence with activity and exercise regimens after heart surgery.

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more. DIF: Applying/Application REF: 791KEY: Intra-aortic balloon pump| nonpharmacologic comfort measuresMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

42. Which statement by the client who had CABG surgery indicates to the nurse that his or her pain is related to the sternotomy and is not anginal in origin? A. "The pain goes down my arm and sometimes into my jaw." B. "My pain increases when I cough or take a deep breath." C. "The nitroglycerin helped to relieve my pain." D. "I feel nausea and shortness of breath with the pain."

B After CABG, the nurse must distinguish between sternal and anginal pain. Typical sternotomy pain is localized, does not radiate, and often becomes worse when the client coughs or breathes deeply. He or she may describe the pain as sharp, aching, or burning. Pain may stimulate the sympathetic nervous system, which increases the heart rate and vascular resistance while decreasing cardiac output. Administer enough of the prescribed analgesic in adequate doses to control pain. Options A, C, and D are descriptors for anginal pain.

44. Which observations would the nurse expect when a client develops mediastinitis after CABG surgery? Select all that apply. A. Anginal-type chest pain B. Fever continuing beyond the first 4 days after surgery C. Bogginess of the sternum D. Redness and drainage from the suture site E. Induration or swelling at the suture site F. Decreased white blood cell count

B, C, D, E After CABG surgery, the nurse would be alert for mediastinitis (infection of the mediastinum) by observing for: fever continuing beyond the first 4 days after CABG; instability (bogginess) of the sternum; redness, induration, swelling, or drainage from suture sites; and an increased white blood cell count (not decreased).

3. A client with chronic stable angina now has chest pressure, cool and clammy skin, blood pressure 150/90 mm Hg, heart rate 100 beats/min, and respiratory rate 32 breaths/min. What are the priorities of collaborative care for this client? Select all that apply. A. Maintain NPO status. B. Relieve chest pain. C. Improve coronary artery perfusion. D. Draw troponin blood samples. E. Improve myocardial oxygenation. F. Relieve nausea.

B, C, D, E This client has experienced a change from chronic stable angina to symptoms that may indicate acute coronary syndrome. The purpose of collaborative care is to decrease pain, decrease myocardial oxygen demand, and increase perfusion (myocardial oxygen supply). Emergency care of the client with chest discomfort includes: assess airway, breathing, and circulation (ABCs); defibrillate as needed; provide continuous ECG monitoring; obtain the client's description of pain or discomfort; obtain the client's vital signs (blood pressure, pulse, respiration); assess/provide vascular access; consult chest pain protocol or notify the cardiac health care provider or Rapid Response Team for specific intervention; obtain a 12-lead ECG within 10 minutes of report of chest pain; provide pain relief medication and aspirin (non-enteric coated) as prescribed; administer supplemental oxygen therapy to maintain an oxygen saturation > 90%; remain calm and stay with the client if possible; assess the client's vital signs and intensity of pain 5 minutes after administration of medication; remedicate with prescribed drugs (if vital signs remain stable) and check the client every 5 minutes; and notify the cardiac health care provider if vital signs deteriorate. Troponin levels would be sent to the laboratory to check for possible MI.

46. Which finding prompts the nurse to immediately contact the surgeon for a client who had a minimally invasive direct coronary artery bypass (MIDCAB)? A. Client has difficulty with coughing and deep breathing. B. Client has acute incisional pain. C. Client has ECG changes including Q waves and ST-segment and T-wave changes in leads V2 to V6. D. Client has chest tube drainage of 80 mL/hr.

C After MIDCAB surgery, the nurse assesses for chest pain and ECG changes (Q waves and ST-segment and T-wave changes in leads V2 to V6) because occlusion of the internal mammary artery (IMA) graft occurs acutely in only a small percentage of clients. If there is any question of acute graft closure, immediately notify the surgeon.

43. Which nursing assessment is specific to a client who had CABG surgery with the radial artery used as the graft? A. Check the fingertips, hand, and arm for sensation and mobility once a shift. B. Take blood pressure every hour on the unaffected arm or use a leg cuff on the legs. C. Assess hand color, temperature, ulnar pulse, and capillary refill every hour initially. D. Assess for and document expected edema, bleeding, and swelling at the donor site.

C Monitor the neurovascular status of the donor arm of clients whose radial artery was used as a graft in CABG (usually the nondominant arm is used). Assess the hand color, temperature, pulse (both ulnar and radial), and capillary refill every hour initially. In addition, check the fingertips, hand, and arm for sensation and mobility at least every 4 hours (not once a shift).

40. Following CABG surgery, a client's body temperature is below 96.8oF (36oC). What measures would the nurse take to rewarm the client? A. Infuse warm IV fluids. B. Do not rewarm because cold cardioplegia is protective. C. Place the client in a warm fluid bath. D. Use lights and thermal blankets to slowly warm the client.

D Hypothermia is a common problem after CABG surgery. Although warm cardioplegia is now the usual operative procedure used, it is not uncommon for the body temperature to drift downward after the client leaves the surgical suite. Monitor the body temperature and institute rewarming procedures if the temperature drops below 96.8° F (36° C). Rewarming may be accomplished with warm blankets, lights, or thermal blankets. The danger of rewarming clients too quickly is that they may begin shivering, resulting in metabolic acidosis, increased myocardial oxygen consumption, and hypoxia.

A nurse is caring for a client in the ICU who has congestive heart failure and is in cardiogenic shock. The client has a pulmonary capillary wedge pressure of 20 mmHg. The nurse understands that this pressure is which of the following? A. Below normal B. Within normal limits C. Above normal D. Consistent with pulmonary edema

Correct Answer: C. Above normal A pulmonary capillary wedge pressure (PCWP) is obtained by wedging a catheter in a tapering branch of one of the pulmonary arteries. It is an estimate of the left ventricular end diastolic pressure or preload of the heart. A PCWP higher than 18 mmHg suggests heart failure. A normal PCWP is 5-12 mmHg. As PCWP increases, pulmonary edema may occur. Levels over 25-30 mmHg are consistent with pulmonary edema. Incorrect Answers: A. Normal pulmonary capillary wedge pressures are 5-12 mmHg. This pressure is above normal. B. A PCWP >12 mmHg is above normal. D. Pulmonary edema occurs at PCWPs above 25-30 mmHg. Vital Concept: The pulmonary wedge pressure or pulmonary capillary wedge pressure is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch. It estimates the left ventricular end diastolic volume and pressure. Increased pulmonary wedge pressure suggest congestive heart failure. Pressures > 20 mm Hg usually result in pulmonary edema.

Which of the following clients should be a priority assessment for the nurse who is receiving the report? A. A 56-year-old client with COPD who has an irregular pulse at a rate of 145/min with a blood pressure reading of 125/80 mmHg B. A 28-year-old client diagnosed with pericarditis who reports pain increased while supine C. A 70-year-old client who is post-op a left femoropopliteal bypass complaining of onset of left foot pain D. A 58-year-old client post repair of a femur fracture sustained in an MVC who is complaining of dyspnea and pleuritic chest pain

Correct Answer: D. A 58-year-old client post repair of a femur fracture sustained in an MVC who is complaining of dyspnea and pleuritic chest pain When prioritizing care, the nurse should give priority to airway, breathing, and circulation. Immobilization, trauma, and hypercoagulable states are the primary risk factors for pulmonary embolism, so the client post repair of a femur fracture is at risk and has clinical signs typical of PE, which include tachycardia, dyspnea, and chest pain. Pulmonary embolism results from embolization of a thrombus from the deep venous system, usually in the lower extremity or pelvis. It can be deadly and requires immediate anticoagulation. Incorrect Answers: A. This client has atrial fibrillation with rapid response in the setting of COPD. Clients with COPD are at greater risk of atrial fibrillation, but this client has a normal blood pressure and is not as much of a priority as the client with a potential PE. B. Pericarditis is inflammation of the lining of the heart. Etiologies include renal failure and viruses. Pain is typically reduced by leaning forward and is exacerbated by the supine position. It is also exacerbated by inspiration or coughing. If the effusion is large, there is a risk of cardiac tamponade, which is characterized by hypotension, jugular venous distention, and muffled heart sounds. C. Although pain may indicate ischemia due to interruption of blood supply distal to the bypass, the signs of ischemia include pain, pallor, paralysis, paresthesia, and pulselessness. Although this client must be evaluated, the priority is the client with potential pulmonary embolism. Vital Concept: Pulmonary embolism refers to obstruction of the pulmonary artery or one of its branches by a thrombus originating in the venous system or right side of the heart, resulting in little to no blood flow with impairment of gas exchange. It results in vasoconstriction with increases in pulmonary vascular resistance, pulmonary arterial pressure, and right ventricle work. PE can lead to hemodynamic collapse and death if it is not recognized and treated early.

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11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

✔ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. DIF: Applying/Application REF: 780KEY: Coronary artery disease| older adult| pathophysiology| nursing assessment MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Health Promotion and Maintenance

25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the S3 sound. What action by the nurse is most appropriate? a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the clients lung sounds.

ANS: D The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the clients lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound. DIF: Applying/Application REF: 773KEY: Coronary artery disease| respiratory assessment| respiratory system| nursing assessment MSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Which statement by a client indicates to the nurse correct understanding of resuming sexual activity in the presence of angina? A. "When I can climb two flights of stairs, it is safe to resume sexual activity." B. "It is best to resume sexual activity in the evening before I go to sleep." C. "If I am unable to walk at least a mile, it is unsafe for me to resume sexual activity." D. "I will discuss alternative methods with my partner as I will no longer be able to resume my previous level of sexual activity."

A In general, a client who can walk one block or climb two flights of stairs without symptoms can usually safely resume sexual activity. Clients can resume sexual intercourse on the advice of the cardiac health care provider, usually after an exercise- tolerance assessment. Suggest that initially clients have intercourse after a period of rest.

34. Which signs and symptoms indicate to the nurse that a client with a myocardial infarction and heart failure is going into cardiogenic shock? Select all that apply. A. Cold, clammy skin with poor peripheral pulses B. Pulmonary congestion and tachypnea C. Bradycardia and hypertension D. Urine output less than 0.5 to 1 mL/kg/hr E. Agitation, restlessness, or confusion F. Systolic BP less than 100 mm Hg

A, B, D, E Manifestations of cardiogenic shock include: tachycardia; hypotension; systolic BP less than 90 mm Hg or 30 mm Hg less than the client's baseline; urine output less than 0.5-1 mL/kg/hr; cold, clammy skin with poor peripheral pulses; agitation, restlessness, or confusion; pulmonary congestion; tachypnea; and continuing chest discomfort. The nurse would document and report these immediately because undiagnosed cardiogenic shock has a very high mortality.

7. Which are characteristics the nurse would expect to find in a client with unstable angina (USA)? Select all that apply. A. Chest pain occurs at rest or with exertion B. Pain causes severe limitation of activities C. Includes chronic stable angina, vasospastic angina, and new- onset angina D. Presents with ECG changes and elevation of troponin levels E. Ischemia does not cause myocardial damage or cell death F. The pain or pressure is poorly relieved by nitroglycerin

A, B, E, F Unstable angina may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerin. Unstable angina includes new- onset angina, vasospastic angina, and pre-infarction angina. Clients with unstable angina may present with ST segment changes on a 12-lead ECG but do not have changes in troponin levels. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death.

4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem- focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client DIF: Understanding/Comprehension REF: 780KEY: Coronary artery disease| psychosocial response| coping| therapeutic communication MSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity

26. A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as: sinus bradycardia. What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

ANS: A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question. DIF: Analyzing/Analysis REF: 780KEY: Coronary artery disease| dysrhythmias| nursing assessment| hemodynamic status MSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses .b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist. DIF: Applying/Application REF: 779KEY: Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agents MSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

24. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

ANS: C A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct. DIF: Remembering/Knowledge REF: 783KEY: Coronary artery disease| inotropic agents| patient educationMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

6. After administering SL nitroglycerin to a client whose baseline blood pressure is 130/80 mm Hg, for which finding would the nurse immediately notify the health care provider? A. Client reports a headache. B. Systolic pressure is 90 mm Hg. C. Anginal pain is somewhat relieved. D. Heart rate is 92 beats/min.

B After administering SL NTG to a client, if the blood pressure (BP) is less than 100 mm Hg systolic or 25 mm Hg lower than the previous reading, lower the head of the bed and notify the cardiac health care provider. If the client is experiencing some, but not complete, relief and vital signs remain stable, another NTG tablet or spray may be used. In 5-minute increments, a total of three doses may be administered in an a

48. Which postprocedure medications would the nurse teach about, before discharge, to a client who had a percutaneous coronary intervention (PCI)? Select all that apply. A. Furosemide B. Clopidogrel C. Metoprolol D. Isosorbide dinitrate E. Docusate F. Aspirin

B, C, D, F Clients who undergo PCI are required to take dual antiplatelet therapy (DAPT) consisting of aspirin and a platelet inhibitor (see Table 35.3 in your text). The health care provider also prescribes a long-term nitrate and beta blocker. An angiotensin- converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is added for clients who have had primary angioplasty after an MI.

49. Which advantages would the nurse teach a client about with regard to robotic heart surgery? Select all that apply. A. Shorter surgical time than traditional CABG surgery B. Shorter hospital stay of just 2 to 3 days C. Decreased pain due to smaller incisions D. Shorter time on the heart-lung bypass machine E. Chest tubes are never needed F. Ability to reach otherwise inaccessible blockage sites

B, C, F Robotic heart surgery is a step toward less invasive open-heart surgery. Surgeons operate endoscopically through very small incisions in the chest wall. Other advantages of robotic procedures include shorter hospital stays (average stay is 2 to 3 days), less pain because of smaller incisions, no need for heart- lung bypass machine, less anxiety for the client, and greater client acceptance, as well as increased ability to reach otherwise inaccessible blockage sites.

A nurse in an ICU is caring for a client who has a pulmonary artery catheter and a pressure monitoring system. The client has a central venous pressure (CVP) of 14 mm Hg and a pulmonary artery wedge pressure (PAWP) of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular Vein Distention D. Dry mucous membranes E. Lower extremity edema

Correct Answers: B. Bilateral crackles in the lungs C. Jugular Vein Distention E. Lower extremity edema The nurse should expect the client to have bilateral crackles in the lungs with an increased CVP and PAWP. Crackles are the sound of excess fluid in the alveoli as a result of leakage of pulmonary capillaries. This represents left-sided heart failure, which is measured indirectly by the PAWP. The nurse should expect the client to have jugular vein distension with an increased CVP and PAWP. This is a finding in right-sided heart failure, measured by the CVP. The nurse should expect the client to have lower extremity edema with an increased CVP and PAWP. The edema is a manifestation of right-sided heart failure, measured by the CVP. Incorrect Answers: A. The client's CVP and PAWP are above the expected reference range, indicating fluid volume excess. The nurse should expect the client to have poor skin turgor when the client's CVP and PAWP are decreased. D. The client's CVP and PAWP are above the expected range, indicating fluid volume excess. The nurse should expect the client to have dry mucous membranes when the CVP and PAWP are decreased. Vital Concept: Hemodynamic assessment can be done in the ICU through a special catheter in the subclavian vein and a pressure monitoring system. Waveforms and numerical values are displayed continuously and certain measurements, such as CVP and PAWP, can be taken intermittently. This kind of monitoring provides valuable information about a client's cardiac and fluid status and response to treatment, especially in cases of heart failure, shock, acute respiratory distress syndrome (ARDS), or sepsis. Complications are uncommon but can include infection, air embolism, and pneumothorax.