Combo with "Ch. 27: Coronary Vascular Disorders" and 3 others

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IV nitroglycerin is given to alleviate

chest pain.

The 30-minute interval is known as "door-to-needle time" for administration of

thrombolytics post MI.

Nitroglycerin is volatile and is inactivated by

heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency.

The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective

"I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain".

The normal LDL range is

100 mg/dL

The goal of treatment is to decrease the LDL level below

100 mg/dL (less than 70 mg/dL for very high-risk patients).

A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first

12-lead ECG

The patient is expected to have a minimum urine output of

30 mL per hour.

The nurse is caring for a male patient who is being evaluated for lipid-lowering medication. The patient's laboratory results reveal the following: Total cholesterol: 230 mg/dL, LDL: 120 mg/dL, and a triglyceride level of 310 mg/dL. Which of the following classes of medications would be most appropriate for the patient based on his laboratory findings? a) Bile acid sequestrants b) HMG-CoA reductase inhibitors c) Nicotinic acids d) Fibric acids

A nurse is caring for a patient post cardiac surgery. Upon assessment, the patient appears restless and is complaining of nausea and weakness. The patient's ECG reveals peaked T waves. The nurse reviews the patient's serum electrolytes anticipating which of the following abnormalities? a) Hypercalcemia b) Hyperkalemia c) Hyponatremia d) Hypomagnesemia

A patient has had a 12-lead -ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes this finding indicates which of the following

A past MI

Following a percutaneous coronary intervention (PCI), a patient is returned to the nursing unit with large peripheral vascular access sheaths in place. The nurse understands that which of the following methods to induce hemostasis after sheath is contraindicated? a) Direct manual pressure b) Application of a vascular closure device c) Application of a mechanical compression device d) Application of a sandbag to the area

Following a percutaneous transluminal coronary angioplasty (PTCA), which of the following medications classifications would be used to prevent thrombus formation in the stent? a) Beta blockers b) Nitrates c) Antiplatelets d) Calcium channel blockers

Antiplatelets Correct Explanation: Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as Plavix or aspirin. Nitrates, beta blockers, and calcium channel blockers would not be used for this purpose.

Application of a sandbag to the area

CVP reading: 1 mmHg

A middle-aged male presents to the ED complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible MI

Chest discomfort not relieved by rest or nitroglycerin

The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The patient's chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming the diagnosis of a current MI

Creatinine kinase-myoglobin (CK-MB) level

Nicotinic acids

A patient presents to the ED complaining of anxiety and chest pain after shoveling heavy snow that morning. The patient says that he has not taken nitroglycerin for months but did take three nitroglycerin tablets and although the pain is less, "They did not work all that well." The patient shows the nurse the nitroglycerin bottle and the prescription was filled 12 months ago. The nurse anticipates which of the following physician orders

Nitroglycerin SL

The patient with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate

PCI Superior outcomes have been reported with the use of PCI compared to thrombolytics.

Percutaneous coronary intervention (PCI)

When a patient who has been diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina

Unstable

What additional assessments related to possible heart failure do you think the nurse should make?

The nurse should assess the patient's heart rate, evidence of edema, weight changes, skin color, temperature, behavioral changes, chest pain, lung sounds, and also question the patient about paroxysmal nocturnal dyspnea (PND). Tachycardia is a compensatory measure to increase cardiac output in HF. Edema may occur in dependant areas, liver, abdominal cavity, or lungs. Check for degree of pitting edema in extremities. Initially, there may be weight gain from fluid retention; later the client may be too ill to eat and may lose weight. Skin may be pale or cyanotic and cool. Decreased cerebral perfusion may lead to confusion, restlessness, or memory and concentration problems. Decreased coronary perfusion may lead to angina-like pain. Lungs should be auscultated for signs of pulmonary congestion, and the patient should be questioned about the presence of a cough and PND to assess for pulmonary involvement from possible left side heart failure.

When the patient diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? a) Refractory b) Intractable c) Variant d) Unstable

Unstable Correct Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Urine output of 40 mL

The nurse is teaching a patient diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should a patient consume per day? a) 2 or fewer b) 4 or 5 c) 2 or 3 d) 7 or 8

a) 2 or fewer Explanation: Two or fewer servings of meat, fish, and poultry are recommended in the DASH diet.

The urine output of 40 mL over a 2-hour period may indicate

acute renal failure.

Clopidogrel (Plavix) is an

antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement.

The patient receiving heparin is placed on bleeding precautions, which can include

applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or constrictive devices (e.g. continuous use of an automatic BP cuff).

The antiplatelet effect of

aspirin does not reverse the effects of heparin.

Hypercalcemia would likely be demonstrated by

asystole.

Which of the following describes difficulty breathing when a patient is lying flat? a) Bradypnea b) Orthopnea c) Paroxysmal nocturnal dyspnea (PND) d) Tachypnea

b) Orthopnea Explanation: Orthopnea occurs when the patient is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

A patient receiving fibrinolytic therapy is at risk for complications associated with

bleeding.

The nurse is analyzing the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which of the following findings indicate the need for follow-up? a) QRS complex that is 0.10 seconds long b) PR interval that is 0.18 seconds long c) QT interval that is 0. 46 seconds long d) ST segment that is isoelectric in appearance

c) QT interval that is 0. 46 seconds long Explanation: The QT interval that is 0.46 seconds long needs to be investigated. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm. If the QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes. The other findings are normal.

Replacement fluids such as

colloids, packed red blood cells, or crystalloid solutions may be prescribed.

Hypertension, obesity, hyperlipidemia, tobacco use, diabetes mellitus, metabolic syndrome, and physical inactivity are modifiable risk factor for

coronary artery disease CAD.

Hypovolemia is the most common cause of

decreased cardiac output after cardiac surgery.

Overall, cardiac rehabilitation is a complete program dedicated to

extending and improving quality of life.

Side effects of nitroglycerin includes

flushing, throbbing headache, hypotension, and tachycardia.

Hypomagnesemia would likely be demonstrated by

hypotension, lethargy, and vasodilation.

his patient requires immediate

invasive therapy or fibrinolytic medications.

Hyperkalemia is indicated by

mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

This classification of medication, beta-adrenergic blocking agents also reduces the incidence of

recurrent angina, infarction, and cardiac mortality. Generally the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm.

The central venous pressure (CVP) reading of 1 is low (2-6 mmHg) and indicates

reduced right ventricular preload, commonly caused by hypovolemia.

Intractable or refractory angina produces

severe, incapacitating chest pain that does not respond to conventional treatment.

Alteplase is a

thrombolytic agent.

Hyponatremia would likely be indicated by

weakness, fatigue, and confusion without change in T-wave formation.

An immediate objective of rehabilitation of the MI patient is to return the patient to

work and a preillness lifestyle.

Nicotinic acids is prescribed for patients with

minimally elevated cholesterol and LDL levels or as an adjunct to a statin when the lipid goal has not been has not been achieved and triglyceride (TG) levels are elevated.

Complications that may occur following a PTCA include

myocardial ischemia, bleeding and hematoma formation, retroperitoneal hematoma, arterial occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and acute renal failure.

A serum potassium level of 4.0 mEq/L is within

normal range.

An increase in myoglobin is

not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

Elevated CK-MB assessment by mass assay is an indicator

of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier.

Nitroglycerin can be taken in anticipation of any activity that may produce

pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops.

The 60-minute interval is known as "door-to-balloon time" for performance of

percutaneous transluminal coronary angioplasty PTCA on a diagnosed MI patient.

An immediate objective of rehabilitation of the MI patient is to

prevent another cardiac event.

The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to

reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise.

Nitroglycerin is very unstable; it should be carried

securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes.

Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by

coronary artery vasospasm.

Unstable angina is also called

crescendo or preinfarction angina and indicates the need for a change in treatment.

Mr. Gruppman asks why his "heart labs" keep increasing and wonders if he is having another heart attack. What is the ideal response that the nurse should provide? a) "No, but it is an indication that the cardiac damage is more extensive than initially thought." b) "Yes, it's possible, so we will be watching your ECG closely." c) "The cardiac marker labs will continue to elevate for 24 hours and then remain high indefinitely." d) "Cardiac marker labs continue to rise for 24 to 48 hours after your heart attack. They should start to fall tomorrow."

d) "Cardiac marker labs continue to rise for 24 to 48 hours after your heart attack. They should start to fall tomorrow." Explanation: CK levels peak in about 24 hours, returning to normal over 2 to 3 days. Troponin peaks in 24 to 48 hours, returning to normal over 5 to 14 days. Myoglobin usually returns to normal within 24 hours.

The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include? a) "Contact your primary care provider if you develop a temperature above 102°F." b) "If any discharge occurs at the puncture site, call 911 immediately." c) "You can take a tub bath or a shower when you get home." d) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

d) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Explanation: The nurse should instruct the patient to complete the following: If the artery of the groin was used, for the next 24 hours, do not bend at the waist, strain, or lift heavy objects; the primary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temperature of 101°F or more. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The patient should not drive to the hospital.

"What time did your chest pain start today?"

alteplase (Activase) are administered if the patient's chest pain lasts longer than

20 minutes, unrelieved by nitroglycerin, ST-segment elevation in the at least two leads that face the same area of the heart, less than 6 hours from onset of pain.

In order to be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)

60 minutes

A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? a. sildenafil (Viagra) b. furosemide (Lasix) c. diazepam (Valium) d. captopril (Capoten)

ANS: A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. DIF: Cognitive Level: Application REF: 773 | 775-776

A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Electrocardiogram (ECG) b. Computed tomography (CT) scan c. Chest x-ray d. Troponin level

ANS: A The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). DIF: Cognitive Level: Application REF: 782

When admitting a patient for a coronary arteriogram and angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? a. The patient's pedal pulses are +1. b. The patient is allergic to shellfish. c. The patient has not eaten anything today. d. The patient had an arteriogram a year ago.

ANS: B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the arteriogram. The other information also is communicated to the health care provider but will not require a change in the usual prearteriogram orders or medications. DIF: Cognitive Level: Application REF: 732

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? a. Administer oral sedative medications. b. Teach the patient about the procedure. c. Ask whether the patient has eaten today. d. Insert a large gauge intravenous catheter.

ANS: B The nurse will need to teach the patient that the procedure is rapid and involves little risk. The other actions are not necessary. DIF: Cognitive Level: Application REF: 731-732

A few days after experiencing a myocardial infarction (MI), the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which response should the nurse make? a. "Where are you planning to go for your vacation?" b. "What do you think caused your chest pain episode?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: B When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Application REF: 788-789

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? a. BP changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 100% to 98%. c. Heart rate increases from 66 to 90 beats/minute. d. Respiratory rate goes from 14 to 22 breaths/minute.

ANS: C A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise. DIF: Cognitive Level: Application REF: 792

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial ischemia b. Anxiety related to perceived threat of death c. Decreased cardiac output related to cardiogenic shock d. Activity intolerance related to decreased cardiac output

ANS: C All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart). DIF: Cognitive Level: Application REF: 786

Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician? a. Complaints of incisional chest pain b. Crackles audible at both lung bases c. Pallor and weakness of the right hand d. Redness on either side of the chest incision

ANS: C The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions. DIF: Cognitive Level: Application REF: 788

To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective? a. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. b. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes. c. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. d. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

ANS: C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. DIF: Cognitive Level: Application REF: 767-768

After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect indigestion as a side effect of nitroglycerin." b. "I can only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." d. "I will help slow down the progress of the plaque formation by taking nitroglycerin."

ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking one nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Application REF: 775-776

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to a. exercise more than usual while the monitor is in place. b. remove the electrodes when taking a shower or tub bath. c. keep a diary of daily activities while the monitor is worn. d. connect the recorder to a telephone transmitter once daily.

ANS: C The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed. DIF: Cognitive Level: Application REF: 729

The nurse has just received change-of-shift report about the following four patients. Which patient should the nurse assess first? a. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge c. 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) d. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Procardia)

ANS: C This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority.

A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI? a. Homocysteine b. C-reactive protein c. Cardiac-specific troponin I and troponin T d. High-density lipoprotein (HDL) cholesterol

ANS: C Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Comprehension REF: 780-781

When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN? a. Perform the initial assessment of the catheter insertion site. b. Teach the patient about the usual postprocedure plan of care. c. Check the rate on the infusion pump used to administer heparin. d. Administer the scheduled aspirin and lipid-lowering medication.

ANS: D Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and administration of intravenous anticoagulant medications should be done by the RN. DIF: Cognitive Level: Application REF: 793

When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. high incidence of cardiovascular disease in older people. d. elevation of the patient's serum low density lipoprotein (LDL) level.

ANS: D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD. DIF: Cognitive Level: Application REF: 767

Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and apical pulse rate. b. fewer complaints of having cold hands and feet. c. improvement in the quality of the peripheral pulses. d. the ability to do daily activities without chest discomfort.

ANS: D Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature. DIF: Cognitive Level: Application REF: 776

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient rates the pain at a level 3 to 5 (0 to 10 scale). b. The patient states that the pain "wakes me up at night." c. The patient says that the frequency of the pain has increased over the last few weeks. d. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Comprehension REF: 771-776

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? a. Myoglobin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL). DIF: Cognitive Level: Application REF: 727 | 733

The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider? a. The patient denies ever having a heart attack. b. The cardiac-specific troponin level is elevated. c. The patient has occasional premature atrial contractions (PACs). d. Crackles are auscultated bilaterally in the mid-lower lobes.

ANS: D The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Application REF: 779-780

When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Check blood pressure. b. Monitor apical pulse rate. c. Monitor for dysrhythmias. d. Ask about chest discomfort.

ANS: D The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Application REF: 784-785

Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain? a. Frequent premature atrial contractions (PACs) b. Inverted P wave c. Sinus tachycardia d. ST segment elevation

ANS: D The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also may suggest a need for therapy, but not as rapidly. DIF: Cognitive Level: Application REF: 780-781

After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective? a. "I will put on the nitroglycerin patch as soon as I develop any chest pain." b. "I will check the pulse rate in my wrist just before I take any nitroglycerin." c. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

ANS: D The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Application REF: 775-776

Can you identify the purpose of each of the medications given to Mr. Gruppman upon his arrival at the ED?

ASA, Inhibits platelet aggregation Morphine sulfate, Reduces pain and workload of the heart, and enhances oxygenation Nitroglycerin, Reduces angina pain, and improves coronary blood flow Atenolol, Reduces myocardial O2 demand Explanation: ASA reduces the possibility of blood clot formation, thus reducing the possibility of recurrent MI and death after MI. Morphine, a vasodilator, reduces preload and afterload of the heart, BP, and HR and relaxes bronchioles, thus enhancing oxygenation; additionally, morphine reduces pain and anxiety. Nitroglycerin relaxes vascular smooth muscle, thereby reducing preload, afterload, and systemic vascular resistance. Beta-blockers (atenolol) reduce HR and BP, thereby reducing the work of the heart; given within a few hours of MI, they can reduce the size of infarction and complications.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the following patient findings requires immediate intervention by the nurse

Altered level of consciousness

Preventative measures utilized to prevent venous stasis include

Application of sequential pneumatic compression wraps or antiembolic stockings; discouraging leg crossing; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

Apply antiembolism stockings, Avoid elevating the knees on the bed, Initiate passive exercises.

hypertension

Approximately 30% of Americans have hypertension. Hypertension places people at an increased risk for cardiovascular and renal disease and for stroke. Primary hypertension is the most prevalent form; however, people may also suffer from secondary hypertension, isolated systolic hypertension, or pseudohypertension. Some people may develop resistant hypertension. Current Joint Commission guidelines define four categories for classification. See chart. Clients often do not experience symptoms until target organ damage has occurred. Symptoms secondary to this damage may include fatigue, dyspnea, dizziness, reduced activity tolerance, and angina. In addition to hypertensive crisis, other acute hypertensive problems include hypertensive emergency and hypertensive urgency. Hypertensive emergency develops over hours to days with BPs over 180/120 and evidence of target organ damage, especially to the central nervous system. Hypertensive urgency develops over days to weeks with severely elevated BP and no evidence of target organ damage. HTN is treated by a combination of lifestyle changes and pharmacologic measures. The many classes of drugs for treatment of HTN include diuretics, calcium channel blockers, ACE inhibitors, angiotension II receptor blockers, direct vasodilators and adrenergic inhibitors, antagonists, and blockers.

Arrange the number against the correct text option in the sequence and click Show Answer. Number the following nursing interventions in order of priority.

Assist patient back to bed Apply O2 at 2L NC Administer nitroglycerine (NTG) Notify physician Explanation: NTG is a vasodilator which can dilate coronary arteries and increase blood flow to cardiac muscle. NTG should be given as ordered if the decrease in activity and oxygen do not relieve pain. Physical exertion can cause increased need for O2 and instigate angina in patient with partial blockages of coronary arteries. Bedrest decreases metabolic needs for O2. This is the first thing the nurse should do. The application of oxygen will increase available to oxygen deprived heart muscle and may relieve the pain associated with angina. The nurse should apply oxygen after the pain is assisted back to bed. The physician should be notified of change in patient condition as soon as possible after the other interventions are carried out.

You are presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? a) Coronary thrombosis b) Arteriosclerosis c) Atherosclerosis d) Raynaud's disease

Atherosclerosis Correct Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.

The nurse is caring for a patient diagnosed with unstable angina receiving IV heparin. The patient is placed on bleeding precautions. Bleeding precautions include which of the following measures

Avoiding continuous BP monitoring

ST elevations

A nurse is caring for a patient in the cardiovascular intensive care unit (CVICU) following a coronary artery bypass graft (CABG). Which of the following clinical findings requires immediate intervention by the nurse? a) CVP reading: 1 mmHg b) Blood pressure: 110/68 mmHg c) Heart rate: 66 bpm d) Pain score: 5/10.

CVP reading: 1 mmHg Correct Explanation: The central venous pressure (CVP) reading of 1 is low (2-6 mmHg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.

List the initial assessments you would make when Ms. Anderson is transferred to your step-down unit for each of the following categories: Cardiac status assessments, Tube assessments, Respiratory assessments, and Fluids and electrolyte balance.

Cardiac status assessments: monitor cardiac rate and rhythm, ECG pattern, BP, peripheral pulses, review and continue to monitor cardiac labs. Tube assessments: check that F/C, chest tubes, and NG tube are all connected and patent; monitor and record output amount and character from each tube. Respiratory assessments: rate, rhythm, pattern; auscultate all fields for any adventitious sounds, assess patient knowledge of incentive spirometry, monitor 02 sats. Fluids and electrolyte balance: correct IV hanging at correct rate, site patent ans symptom-free; monitor labs; measure output from all tubes.

As you continue to care for Ms. Anderson, what assessments would you add? List these assessments for each of the following categories: Cardiac, Tubes, Fluid and electrolytes, and Pain.

Cardiac: Observe for s/sx of impending cardiac failure, cardiac tamponade, or MI. Tubes: Anticipate removal of F/C and monitor subsequent voiding and urine output pattern (should >30mL/hr). Chest tube drainage should be <200 ml and decrease daily. Anticipate removal of NG tube and assess for signs of distension or n/v. Fluid and electrolytes: Any trending abnormality in electrolytes must be noted and reported to the MD. Potassium, magnesium, sodium, and calcium abnormalities are of particular concern in the post-op cardiac patient. Glucose may be elevated, even in the non-diabetic patient due to surgical stress. Pain: Anticipate weaning patient off PCA onto oral narcotic pain relievers.

CAD

Coronary artery disease is one of the leading causes of death in the United States. CAD develops when atherosclerotic plaques build up in the endothelium of the coronary arteries, narrowing and/or blocking the coronary arteries. This decreases blood flow to the tissues, including cardiac muscle tissue. Additionally, plaques and formed thrombi can break off, leading to MI. It is believed that injury to the endothelium and the inflammatory response set the stage for plaque formation. A number of factors from hyperlipidemia and elevated homocysteines to modifiable disease states such as HTN and diabetes can contribute to endothelial injury. Measures to prevent the development of CAD in high-risk patients and to prevent the progression of diagnosed CAD include lifestyle modifications and lipid-lowering drugs. Clients with CAD are at risk for angina, MI, and sudden cardiac death.

9:01 A.M. Good! You've recorded Mrs. Downs's systolic pressure at 112 and diastolic pressure at 64. Now you must document your findings. What will you document in relation to her blood pressure?

Date Time Patient appears somewhat anxious regarding the need to learn to self administer IV antibiotics; states, "I don't want to mess up. What if I make things worse?" Provided emotional support and reassurance. Explained rationale and procedure for measuring blood pressure Blood pressure reading obtained in right arm 112/64

A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following

Decreases resting heart rate

Mr. Easton will begin to monitor his BP at home after his hospital discharge. List at least three teaching points for home blood pressure monitoring.

Do not smoke or drink caffeine for 30 minutes before taking BP; rest quietly for at least 5 minutes before taking BP. While measuring BP, sit with both feet on the floor and forearm supported at heart level. Wrap cuff snugly 1 inch above the antecubital space. Wait at least 1 minute before taking another reading to allow circulation to return to normal in arm. Factors that can briefly increase BP include cigarette smoking, drinking caffeine, and increased activity. Incorrect technique while taking a BP can result in a falsely higher or lower BP reading.

Elevated blood pressure, Obesity

9:03 A.M. You've assisted Mrs. Downs to an appropriate position for the measurement of blood pressure using the brachial artery of her right arm. Now you must correctly place the cuff of the sphygmomanometer to obtain an accurate reading. The steps to correctly place the cuff of the sphygmomanometer are given here. They're out of order Palpate the location of the brachial pulse on the patient's arm. Expose the brachial artery by removing garments above the area where the cuff will be placed. Center the bladder of the cuff over the brachial artery. Wrap the cuff around the arm smoothly and snugly.

Expose the brachial artery by removing garments above the area where the cuff will be placed. Palpate the location of the brachial pulse on the patient's arm. Center the bladder of the cuff over the brachial artery. Wrap the cuff around the arm smoothly and snugly. Explanation: 1. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed. Clothing over the artery interferes with the ability to hear sounds and may cause inaccurate blood pressure readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings. 2. Palpate the location of the brachial pulse on the patient's arm. Identification of the brachial pulse allows for accurate placement of the cuff and stethoscope. 3. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about one to two inches above the inner aspect of the elbow. The tubing should extend from the edge of the cuff nearer the patient's elbow. Pressure in the cuff applied directly to the artery provides the most accurate readings. If the cuff gets in the way of the stethoscope, readings are likely to be inaccurate. A cuff placed upside-down with the tubing toward the patient's head may give a false reading. 4. Wrap the cuff around the arm smoothly and snugly, and fasten it securely. Do not allow any clothing to interfere with the proper placement of the cuff. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff too loosely wrapped results in an inaccurate reading.

What does Ms. Bailey's "elevation above normal" value in HgbA1c indicate?

Glycosylated hemoglobin (A1C) reflects average blood glucose over a period of 2 to 3 months, approximating the average lifespan of a red blood cell (RBC). When glucose levels are elevated, the glucose molecules attach to RBCs for the life of the RBCs (120 days). Therefore, increased HgbA1c reflects poor control of glucose. This appears to be true in Ms. Bailey's case.

Ms. Anderson is worried that she might have a heart attack while exercising at her health club. As the nurse, how will you address her fears?

Heart attacks occur when there is irreversible ischemia resulting in tissue death. Chronic stable angina results in reversible ischemia with reperfusion of the affected areas. Ms. Anderson's new beta-blocker should help reduce the incidence of exercise-induced angina; if it does not, she should tell her MD, who may be able to increase the dosage. Ms. Anderson should stop exercising and take her sublingual NTG if she experiences angina while exercising. She may need to consider modifying her exercise program to a level that will not induce angina. Isometric exercises of the arms (weight lifting) are particularly prone to inducing angina. Ms. Anderson is not experiencing irreversible ischemia, the hallmark of MI. Medications and modification of her exercise program will help reduce her angina attacks. Continuing to exercise will reduce her risk factors for CAD, the primary cause of angina.

Heart failure

Heart failure affects about 5 million people in the United States and results in about 300,000 deaths annually. It is more common in people over age 65 and in African-Americans, who tend to develop HF at an earlier age. It affects men and women in near equal proportions. Risk factors for HF include hypertension, diabetes, coronary artery disease and valvular disorders, high cholesterol, obesity, and cigarette smoking. While pathology determination is based on systolic or diastolic failure, HF is often referred to as left-sided or right-sided failure. The most common form is left-sided failure which causes back-up of blood flow into the left atrium and lungs, leading to increased pulmonary pressure and pulmonary edema. Right-sided failure results from left-sided failure and pulmonary hypertension, causing blood flow backup in the right atrium and general circulation; this leads to peripheral edema, hepatomegaly, splenomegaly, vascular congestion in the GI tract, and jugular venous congestion. In addition to diuretics, ACE inhibitors, beta-blockers, and digitalis, pharmacologic management may include nitroglycerin to reduce preload, medications to reduce afterload (such as nitroprusside), aldosterone receptor antagonists and vasodilators. BiDil, a isosorbide dinitrate/hydralazine combination drug has recently been approved for use in African-Americans already being treated with standard treatment. Acutely severe cases of HF may require hemodynamic monitoring and beta-adrenergic agonists (such as dopamine), and eventually heart transplantation.

Which of the following in an inconsistent manifestation of metabolic syndrome? a) Hypotension b) Chronic inflammation c) Insulin resistance d) Dyslipidemia

Hypotension Correct Explanation: Metabolic syndrome consists of insulin resistance, dyslipidemia, hypertension, and chronic inflammation.

Ms. Anderson wonders how so many different factors can contribute to her chest pain. Can you match the causes of her chest pain with their effects?

Heavy meals, Diverts blood, decreasing blood flow in the coronary artery system Stress, Stimulates the sympathetic nervous system and increases cardiac workload Exercise, Increases heart rate and myocardial O2 demand Explanation: Heavy meals divert blood to the GI tract, decreasing flow to the coronary arteries. Stress stimulates the SNS, increasing cardiac workload and O2 demand of the heart. Exercise increases O2 demand. Other precipitating factors for chronic stable angina include: temperature extremes, tobacco use, legal and illicit pharmaceuticals, and circadian rhythms (more occur in the AM after awakening).

The nurse is reviewing the laboratory results for a patient diagnosed with coronary artery disease (CAD). The patient's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as which of the following

High

High Explanation: The normal LDL range is 100 mg/dL to 130 mg/dL. A level of 115 mg/dL is considered to be high. The goal of treatment is to decrease the LDL level below 100 mg/dL (less than 70 mg/dL for very high-risk patients).

Hyperkalemia

When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hypercalcemia b) Hyponatremia c) Hyperkalemia d) Hypomagnesemia

Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation.

A patient admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which of the following medications will the nurse administer to relieve the patient's anxiety and decrease cardiac workload

IV morphine

Improvement of the quality of life

The nurse writes a nursing diagnosis for Mr. Gruppman of Ineffective Cardiac Tissue Perfusion related to decreased coronary blood flow with a goal to decrease chest pain. Can you list at least two interventions with rationales for this goal?

Interventions (I) and their rationales (R) are listed below: I: Assess pain, including location, intensity, radiation, duration, factors affecting pain as well as associated symptoms such as nausea, etc. R: Establish a baseline with which to compare post-therapy symptoms; help rule out any other chest/abdomen conditions that include chest discomfort. I: Monitor ECG. R: A change in ECG strips could indicate extension of damage or identify life-threatening dysrhythmias. I: Monitor BP, heart sounds and rate, LOC, I&O, skin color. R: Decreased BP, LOC, and urine output may indicate decreased cardiac output; increased heart rate may indicate compensatory measure to maintain perfusion. I: Administer O2; R: increase O2 supply to damaged myocardium. I: Administer meds as ordered. R: ASA, nitroglycerine, beta-blockers, morphine, and ACE inhibitors are the first-line defense in preserving myocardial tissue and preventing further damage. I: Bedrest with gradual increase in activity as ordered. R: Rest reduces myocardial O2 requirements. I: Alleviate anxiety and fear. R: Both precipitate stress response, which increases O2 consumption and decreases pain threshold.

Ms. Anderson looks at her new prescriptions and exclaims "So many meds! Why do I need all of these?" The nurse explains the use of these medications. Can you match the medication with its effect?

Lopressor, Delays the onset of exercise induced ischemia ASA, Prevents blood clots Lipitor, Lowers cholesterol levels NTG, Relieves acute angina pain Explanation: Beta-adrenergic blockers (Lopressor) reduce cardiac O2 demand by decreasing heart rate, BP, vascular resistance, and myocardial contractility; these actions help delay the onset of exercise-induced angina. Nitrates (Imdur and sublingual NTG) dilate veins (and in large doses, the arteriole bed), which decreases cardiac workload and myocardial O2 demand. A common side effect of nitrates is headache; Tylenol may be taken with Imdur to prevent this. Statins (Lipitor) lower cholesterol and reduce the risk for CAD, the primary cause of angina.

An elevation in ST segment in two contiguous leads is a key diagnostic indicator for

MI (i.e. ST elevation myocardial infarction, STEMI). T

Ms. Bailey asks why she is not receiving her metformin for her diabetes. How should the nurse respond to her query?

Metformin causes an increased risk of acute renal failure (ARF) and lactic acidosis with use of iodine based contrasts. Metformin should be discontinued or held for 48 hours prior to an angiogram (and for 48 hours afterward until renal function is confirmed normal).

Most MIs occur in the left ventricle as a result of a thrombus in a coronary artery. Perfusion to the area distal to the thrombus is halted, resulting in necrosis of the affected myocardium. The patient may develop a fever due to the resultant inflammatory process and may develop elevated glucose levels due to catecholamine release. The development of collateral circulation during this time helps increase perfusion and limits the size of the injury. Other causes for MI may include increased demand for O2 which the myocardium cannot meet, decreased O2 supply (e.g., anemia, hypotension), or vasospasm of a coronary artery. In addition to the classic symptoms of MI (severe pain unrelieved by rest or nitroglycerin, nausea and vomiting, cool, clammy skin), atypical symptoms may appear in certain groups. Women may experience fatigue, atypical discomfort, or shortness of breath; elderly people may present with confusion, a new dysrhythmia, or edema; diabetic people may exhibit no symptoms at all ("silent MI"). ECG changes following MI take place over time; ST segment elevation, the hallmark ECG change, evolves within hours and returns to baseline after successful reperfusion therapy and within 1 to 6 weeks; T wave inversion occurs within 1 to 3 days and may persist for weeks to months; abnormal Q waves appear within 1 to 3 days and may remain indefinitely. An abnormal Q wave without ST segment or T wave abnormalities indicates an old MI. In addition to pharmacologic treatment, the patient with acute MI may undergo an emergency percutaneous coronary intervention (PCI). During PCI, which must be performed within 90 minutes of arrival, coronary catheterization locates the thrombus and removes it and the underlying atherosclerotic plaque. Patients with MIs are often discharged before the healing process is complete, another reason cardiac rehab is so important. Scar tissue begins to form at 10 to 14 days and is most susceptible to increased stress during this time period. By 6 weeks post-MI, most necrotic tissue has been replaced by scar tissue. These scarred areas, which are less compliant than surrounding healthy myocardial tissue, may lead to ventricular dysfunctions and heart failure. Complications of MI include dysrhythmias, heart failure, cardiogenic shock, ventricular aneurysm, pericarditis, and Dressler syndrome. Patients may be discharged from the hospital on several medications and should expect to be in a cardiac rehabilitation program for 2 to 12 weeks.

Explain the rationale for changing Mrs. Melnik's furosemide from oral dosing to IV.

Mrs. Melnik is experiencing pulmonary edema and requires rapid and effective diuresis. Furosemide is a potent diuretic and is often used as a first-line agent in ADHF to reduce intravascular volume and preload. Onset of IV furosemide occurs within 5 minutes and peaks at 20 to 60 minutes. IV furosemide should be administered over 1 to 2 minutes to prevent ototoxicity. The client should be observed for signs/symptoms of hypovolemia, electrolyte imbalance (hypokalemia and hypochloremia), and thrombophlebitis.

A patient presents to the ED complaining of anxiety and chest pain after shoveling heavy snow that morning. The patient says that he has not taken nitroglycerin for months but did take three nitroglycerin tablets and although the pain is less, "They did not work all that well. " The patient shows the nurse the nitroglycerin bottle and the prescription was filled 12 months ago. The nurse anticipates which of the following physician orders? a) Nitroglycerin SL b) Chest x-ray c) Ativan 1 mg orally d) Serum electrolytes

Nitroglycerin SL Correct Explanation: Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired and the nurse should anticipate administering nitroglycerin to assess if the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the patient's chest pain.

9:03 A.M. You've applied the cuff of the sphygmomanometer correctly. Since Mrs. Downs is a new patient, a baseline reading is not available. Now you have to continue with the steps to estimate Mrs. Downs's systolic blood pressure. Estimating systolic blood pressure prevents underestimating it, ensuring accurate identification of the first sound. The steps are given here, but they're out of order.

Palpate the brachial pulse by pressing it gently with your fingertips. Tighten the screw valve on the air pump bulb. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. Explanation: 1. Palpate the brachial pulse by pressing it gently with your fingertips. Palpation allows for measurement of the approximate systolic reading. 2. Tighten the screw valve on the air pump bulb. The bladder within the cuff will not inflate with the valve open. 3. Inflate the cuff while continuing to palpate the artery. Inflation is necessary to apply pressure to the artery. 4. Note the point on the gauge where the pulse disappears. The point where the pulse disappears provides an estimate of the systolic pressure. To identify the first Korotkoff sound accurately, the cuff must be inflated to a pressure above the point at which the pulse can no longer be felt.

9:04 A.M. You've noted the point on the gauge where the pulse disappears. This is the estimate of the systolic reading. You must deflate the cuff and wait for 15 seconds to allow the blood to refill and circulate through the arm before you continue with the blood pressure measurement. The steps to record the blood pressure measurement are given here. They're out of order.

Place stethoscope firmly over the brachial artery where you palpated it. Tighten the screw valve on the air pump bulb. Inflate the cuff to 30 mm above the estimated systolic pressure. Open the valve and allow the air to escape slowly. Note the point at which the first faint, but clear sound is heard. Note the pressure at which the sound first becomes muffled and the point it disappears. Allow the remaining air to escape quickly. Clean the stethoscope head with an alcohol prep and perform hand hygiene. Explanation: 1. Place the stethoscope firmly over the location where you palpated the brachial artery, making sure the stethoscope does not touch the cuff. Having the bell or diaphragm directly over the artery allows for readings that are more accurate. Heavy pressure on the brachial artery distorts the shape of the artery and the sound. Placing the bell or diaphragm away from clothing and the cuff prevents noise, which may distract you from the sounds made by blood flowing through the artery. 2. Tighten the screw valve on the air pump bulb so that the air you pump in doesn't escape. 3. Inflate the cuff to 30 mm above the point at which you palpated and estimated the systolic pressure. Increasing the pressure above the point where the pulse disappeared ensures a period of silence before hearing the first sound that corresponds with the systolic pressure. It prevents misinterpreting phase II sounds as phase I. 4. Open the valve on the bulb and allow the air to escape slowly, allowing the gauge to drop 2 to 3 mm per heartbeat. Allows for readings that are more accurate. 5. Note the point on the gauge at which there is an appearance of the first faint, but clear sound that slowly increases in intensity. Note this number as the systolic pressure reading. Systolic pressure is the point at which the blood in the artery is first able to force its way through the vessel at a similar pressure exerted by the air bladder in the cuff. The first sound is phase I of Korotkoff sounds. 6. Note the pressure at which the sound first becomes muffled and the point at which the sound completely disappears. This may occur separately or at the same point. The point at which the sound changes correspond to phase IV Korotkoff sounds and is considered the first diastolic pressure reading. This is used as the diastolic pressure recording in children. The last sound heard is the beginning of phase V and is the second diastolic reading. In adults, the point at which the sound disappears is recorded as the diastolic pressure. 7. Allow the remaining air to escape quickly to allow the blood to circulate normally through the limb. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings. 8. Clean the stethoscope head with an alcohol prep and perform hand hygiene to deter the spread of microorganisms.

The nurse is caring for a patient following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which of the following medications to neutralize the unfractionated heparin the patient received

Protamine sulfate

During his annual physical exam, a 62-year-old male client reports experiencing chest pain and palpitations during and after his morning jogs. Family history reveals coronary artery disease. The nurse should instruct the client in the following to reduce the client's cardiac risk? a) Smoking cessation b) Antioxidant supplements c) Exercise avoidance d) Protein-rich diet

Smoking cessation Correct Explanation: The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight. Antioxidant supplements, such as those containing vitamin E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use.

What pre-procedure education should the admitting nurse give to Mr. Kingsolver about the cardiac catheterization and angiography?

The admitting nurse needs to educate Mr. Kingsolver about the following: He will lie on a table for about 2 hours, under light IV sedation. He may feel an occasional pounding sensation in his chest (as the catheter touches his heart) or flushing throughout his body (as the contrast material is injected). He may feel he needs to void (as the contrast material is injected). These feelings should last less than a minute. He will be sedated, but will be awake enough to follow directions; he may be asked to cough or take a deep breath and hold it. Coughing will clear the contrast from his arteries or help correct a dysrhythmia. Deep breathing will lower the diaphragm, allowing a better view of the heart.

Explain the rationale for changing Mr. Easton's medication to a combination drug.

The drugs are from two different classes and correct different pathophysiologic factors for HTN. A second drug of a different class should be added if the first drug does not control BP. Blood pressure is the force blood exerts against vessel walls; it must be high enough to maintain adequate tissue perfusion, yet not so high it causes organ damage. Factors affecting BP include cardiac output (CO), systemic vascular resistance (SVR), sympathetic nervous system activity, and enzymes excreted from the vascular endothelium, endocrine and renal systems. HCTZ (a thiazide diuretic) helps reduce CO by increased excretion of NA+ and water. Metoprolol (a beta-blocker) reduces CO, vasoconstriction, and renin secretion by blocking beta-adrenergic receptors.

What is the desired BP for Ms. Bailey, given her medical history?

The goal of hypertension management is to prevent complications and death by achieving a BP of less than 130/80 for patients with diabetes mellitus or chronic kidney disease. This is lower than the goal of 140/90 for the general population.

angina

The most important cause of angina is coronary artery disease causing a 75% or more blockage of at least one coronary artery. Precipitating factors lead to either an increased demand for cardiac O2 or a decreased supply of cardiac O2; both conditions lead to myocardial ischemia. Perfusion to the ischemic areas in chronic stable angina is restored by rest and/or sublingual NTG. In addition to chronic stable angina, patients may experience silent angina (ischemia without symptoms; this often occurs in diabetic patients with neuropathy), nocturnal angina (occurs only at night, not necessarily during sleep), decubitus angina (occurs only when lying down, relieved by standing), or Prinzmetal's angina (often occurs at rest in response to coronary artery spasm; it may be relieved by moderate exercise or disappear spontaneously). The patient may be initially diagnosed with unstable angina, or the patient with chronic stable angina may progress to unstable angina. This is a worsening pattern that occurs without warning and at rest. Clinical manifestations of angina range from mild chest discomfort to crushing pain, and feelings of anxiety to feelings of impending death. Women with angina are likely to experience atypical symptoms, including fatigue, weakness, and shortness of breath. Elderly people may simply experience dyspnea. Angina is medically treated by both short- and long-acting nitrates (which are vasodilators, primarily in the venous system, that decrease preload, which in turn decreases myocardial O2 consumption; this decreases ischemia and relieves pain); by beta-adrenergic blockers which reduce cardiac rate and contractility (reducing myocardial O2 consumption); and by calcium channel blockers which lower heart rate and increase strength of contraction, thus decreasing cardiac workload and myocardial demand for O2. Calcium channel blockers also increase myocardial O2 supply by dilating coronary arterioles. Patients with angina also receive anticoagulant and antiplatelet medication to prevent thrombosis and attendant decreased blood flow. Patients with angina related to coronary artery blockage may be candidates for surgical intervention including percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Additional measures include lifestyle changes to reduce the risk of CAD.

Mr. Gruppman expresses that he is worried he is going to have another heart attack and end up "crippled." How should the nurse respond to his reaction?

The nurse should perform the following nursing interventions: Listen to Mr. Gruppman in a non-judgmental, interested manner. Encourage him to express what, specifically, he is afraid of. Determine what Mr. Gruppman knows about how an MI occurs and what his course of rehab will be. Correct any misconceptions and provide additional information as needed. Assess Mr. Gruppman's social/family support group and try to include them if appropriate; fear and anxiety perpetuate the stress response and hinder healing. Establish a therapeutic relationship with Mr. Gruppman that allows him to express his fears. Assessing his knowledge and beliefs, and correcting misconceptions will help lower anxiety levels; knowledge will give him a sense of control. Mr. Gruppman will likely be encouraged to join a MI support group when he is in cardiac rehab, pulling in his own social/family support system will also help him in his recovery.

Mr. Kingsolver is given a prescription for nitroglycerin 0.4 mg SL tablets. What patient education does the nurse provide to Mr. Kingsolver on how to take sublingual nitroglycerin and the common side effects that occur?

The nurse tells Mr. Kingsolver that he should place a tablet under his tongue at the first sign of chest pain, and allow it to dissolve. He should not swallow or chew the tablet, and may take another tablet 5 minutes later, if needed. He should not take more than three tablets, 5 minutes apart. If the pain is not better after the third tablet, he should go to the hospital immediately. The nurse also tells Mr. Kingsolver that he may experience headache, palpitations, and dizziness (especially after changing positions) after using nitroglycerin. She explains that nitroglycerin relieves angina pain by relaxing the smooth muscle of the vasculature. Dilation of the vessels reduces systemic vascular resistance (SVR) and afterload and it decreases the amount of blood returning to the heart, thereby decreasing preload. The nurse emphasizes that nitroglycerin should be kept in the original glass container to protect it from light and moisture, the cotton ball should be discarded, and the bottle dated when opened. The medication should be discarded 6 months after opening

The nurse gives Ms. Anderson instructions on the use of her sublingual NTG. What aspects of patient education should the nurse elaborate?

The nurse tells Ms. Anderson that she should place a tablet under her tongue at the first sign of chest pain and allow it to dissolve; she should not swallow or chew the tablet; she may take another tablet 5 minutes later if needed, and a third one 5 minutes after that, if needed; she should not take more than three tablets, 5 minutes apart. If the pain is not better after the third tablet, she should go to the hospital immediately. The nurse also tells Ms. Anderson that she may experience headache, palpitations, and dizziness (especially after changing positions) after using nitroglycerin. She explains that nitroglycerin relieves angina pain by relaxing the smooth muscle of the vasculature. Dilation of the vessels reduces systemic vascular resistance (SVR) and afterload and it decreases the amount of blood returning to the heart, thereby decreasing preload. The nurse emphasizes that nitroglycerin should be kept in the original glass container to protect it from light and moisture, the cotton ball should be discarded, and the bottle dated when opened. The medication should be discarded six months after opening to ensure full potency.

List at least four teaching points the nurse should cover when Mrs. Melnik is discharged.

The patient should be provided information regarding balancing exercise and energy conservation. Recent research has shown that exercise (cardiac rehab training) does improve symptoms in HF, however, balancing exercise with energy conservation is also a concern in HF. Measures to prevent/monitor for future fluid volume overload should be taught. The patient must be told about the importance of a reduced salt diet, fluid restrictions as ordered by MD and daily weights. A restricted salt diet will help decrease edema and prevent fluid overload. The patient should be protected against respiratory infection with flu and pneumonia vaccines. Medication education should include how to take drugs, signs of toxicity, how to take BP and pulse, and when to hold the medication and call the MD. Finally, Mrs. Melnik should be taught early signs/symptoms of ADHF and know when to call her MD.

The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction remains elevated for as long as 3 weeks? a) Troponin b) CK-MB c) Myoglobin d) Total CK

Troponin Explanation: Troponin remains elevated for a long period, often as long as 3 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin returns to normal in 12 hours. Total CK returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur? a) Internal bleeding b) Worsening angina c) Thrombocytopenia d) Formation of blood clots

You selected: Worsening angina Correct Explanation: Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or thrombocytopenia.

It's 9:00 a.m. You're visiting Mrs. Downs at her home as part of her scheduled home healthcare. She is somewhat anxious and nervous about learning how to administer the antibiotics herself. In response to your greeting she says: "I don't want to mess up. What if I make things worse?" She seems anxious, doesn't she? What will you say to her? What should you explain to Mrs. Downs regarding her blood pressure measurement?

You should allow Mrs. Downs to communicate her thoughts and feelings about her situation, the change in her health status, and any questions she may have. Explain the rationale for the measurement and the steps that are involved. You should explain that, now that she's at home, you will be monitoring her condition and responding to any symptoms or problems she may be having. Part of your assessment includes obtaining a set of vital sign measurements, including a blood pressure reading. Explain that a cuff will be placed around her arm and it will become tight and may be uncomfortable, but only for a minute or two.

A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient's BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next? a) "Have you taken your prescribed Catapres today?" b) "Do you have a dry mouth or nasal congestion?" c) "Are you having chest pain or shortness of breath?" d) "Did you take any medication for your headache?"

a) "Have you taken your prescribed Catapres today?" Explanation: The nurse must ask if the patient has taken his prescribed Catapres. Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of Catapres is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire if the patient has taken his prescribed HTN medication given the patient's severely elevated BP.

The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective? a) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". b) "After taking two tablets with no relief, I should call emergency medical services." c) "Side effects of nitroglycerin include, flushing, throbbing headache, and hypertension". d) "I can put the nitroglycerin tablets in my daily pill dispenser with my other medications".

a) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". Explanation: Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin includes: flushing, throbbing headache, hypotension, and tachycardia.

A nurse has provided discharge instructions to a patient who had an implantable cardioverter defibrillator (ICD) implanted. Which of the following statements, made by the patient, indicates the need for further teaching? a) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." b) "I can play golf with my son in about 2 or 3 weeks." c) "I should tell close friends and family members that I have an ICD." d) "I will document the date and time if my ICD fires."

a) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." Explanation: The patient does not need to take a CPR class. However, it is recommended that the family members and friends of a patient who has an ICD learn CPR. The other statements indicate that the nurse's teaching was effective.

Mr. Gruppman wonders why his blood sugar is so high - "I don't need diabetes on top of everything else!" What should the nurse tell him? a) "Your nervous system is causing increased levels of sugars and fats to help your damaged heart muscle function." b) "You need the increased sugars to heal your heart." c) "Diabetes is a potential complication of MI." d) "It is probably a lab error, don't worry about it."

a) "Your nervous system is causing increased levels of sugars and fats to help your damaged heart muscle function." Explanation: Catecholemines, released after infarction takes place, precipitate glycogenolysis and lipolysis. The extra glucose and free fatty acids are used for anaerobic metabolism by the oxygen-depleted myocardium. They are not used in the healing process, which involves scar formation, and diabetes is not a complication of MI. Temperature increases may occur due to the inflammatory process following tissue necrosis

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) 140, 90 b) 120, 70 c) 130, 80 d) 110, 60

a) 140, 90 Explanation: According to the categories of blood pressure levels established by the Joint National Committee (JNC) VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult. Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult. Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.

A 1-minute ECG tracing of a patient with a regular heart rate reveals 25 small square boxes within an RR interval. The nurse correctly identifies the patient heart rate as which of the following? a) 60 bpm. b) 80 bpm c) 70 bpm d) 100 bpm

a) 60 bpm. Explanation: A patient's HR can be obtained from the ECG tracing by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.

Mr. Kingsolver returns to the short-stay unit following his procedure. His catheterization was accomplished via right femoral artery access. Which of the following would the nurse expect to do? Select all that apply. a) Administer IV fluids and encourage oral fluids b) Maintain bed rest for 30 minutes c) Monitor color, motion, sensitivity (CMS) and pulses in his right leg d) Monitor the puncture site for bleeding/hematoma e) Raise the head of his bed if he experiences a vasovagal reaction

a) Administer IV fluids and encourage oral fluids, c) Monitor color, motion, sensitivity (CMS) and pulses in his right leg, d) Monitor the puncture site for bleeding/hematoma Explanation: Mr. Kingsolver will be on bed rest for 2 to 6 hours depending on what type of closure device was used after the procedure. The nurse will closely monitor the puncture site for bleeding or hematoma formation. Peripheral pulses and CMS should be monitored every 15 minutes for the first hour, then hourly, if stable. The patient should be monitored for cardiac dysrhythmias; if a vasovagal response occurs, the patient's legs should be raised above the level of his head and IV fluids and IV atropine administered. Mr. Kingsolver should be instructed to immediately report any chest pain and should be assisted his first time out of bed. Discharge instructions should include signs/symptoms to report, how to avoid infection (including shower, not a tub bath, until healed), and measures to avoid straining.

9:02 A.M. Now that you've identified steps to prevent infection, you need to assess Mrs. Downs for conditions that would contraindicate the use of any of her limbs for blood pressure measurement. What will you assess for before selecting an extremity for measuring blood pressure? a) Assess for the presence of factors that may influence blood pressure reading. b) Breast or axilla surgery on the same side as the extremity. c) Baseline blood pressure reading. d) Presence of an intravenous infusion, a cast, or an arteriovenous shunt. e) Size of the patient's limb. f) Injury or disease of the limb. g) The patient's ability to follow instructions. h) Presence of tattoos and scars.

a) Assess for the presence of factors that may influence blood pressure reading., b) Breast or axilla surgery on the same side as the extremity., c) Baseline blood pressure reading., d) Presence of an intravenous infusion, a cast, or an arteriovenous shunt., e) Size of the patient's limb., f) Injury or disease of the limb. Explanation: You must assess for the presence of an intravenous infusion, a cast or arteriovenous shunt in the limb, breast or axilla, surgery on the side of the extremity, or injury or disease of the limb. These conditions would contraindicate the use of that limb for blood pressure measurement. Knowledge of factors that may influence the blood pressure reading allows for accurate interpretation of the reading. You should also assess the size of the limb so that the appropriate sized cuff can be used. Also, note the patient's baseline reading, if available, for comparison.

Which of the following terms is used to describe the ability of the heart to initiate an electrical impulse? a) Automaticity b) Contractility c) Excitability d) Conductivity

a) Automaticity Explanation: Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which of the following measures should the nurse complete to prevent deep venous thrombosis (DVT) and possible pulmonary embolism (PE) development? Select all that apply. a) Avoid elevating the knees on the bed. b) Initiate passive exercises. c) Apply antiembolism stockings. d) Place pillows in the popliteal space. e) Encourage the crossing of the legs.

a) Avoid elevating the knees on the bed., b) Initiate passive exercises., c) Apply antiembolism stockings. Explanation: Preventative measures utilized to prevent venous stasis include: Application of sequential pneumatic compression wraps or antiembolic stockings; discouraging leg crossing; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

The nurse is caring for a patient following the insertion of a permanent pacemaker. Which of the following discharge instructions are appropriate for the nurse to review with the patient? Select all that apply. a) Avoid handheld screening devices in airports. b) Wear a medical alert noting the presence of a pacemaker c) Refrain from walking through antitheft devices. d) Check pulse daily, reporting sudden slowing or increase. e) Avoid the usage of microwave ovens and electronic tools

a) Avoid handheld screening devices in airports., b) Wear a medical alert noting the presence of a pacemaker, d) Check pulse daily, reporting sudden slowing or increase. Explanation: Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the patient should be instructed initially to restrict activity on the side of implantation. Patients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Patients should walk through antitheft devices quickly and avoid standing in or near these devices. Patients can safely use microwave ovens and electronic tools.

The nurse recognizes which of the following lab tests is a key diagnostic indicator of heart failure? a) Brain natriuretic peptide (BNP) b) Complete blood count (CBC) c) Blood urea nitrogen (BUN) d) Creatinine

a) Brain natriuretic peptide (BNP) Explanation: The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

The nurse is participating in the care of a client requiring emergent defibrillation. The nurse will complete the following steps in which order? a) Call "clear" three times ensuring patient and environmental safety. b) Turn on the defibrillator and place it in "not sync" mode. c) Charge the defibrillator to the prescribed voltage. d) Deliver the prescribed electrical charge. e) Apply the multifunction conductor pads to the patient's chest.

a) Call "clear" three times ensuring patient and environmental safety., b) Turn on the defibrillator and place it in "not sync" mode., c) Charge the defibrillator to the prescribed voltage., d) Deliver the prescribed electrical charge., e) Apply the multifunction conductor pads to the patient's chest. Explanation: This is the sequence of events the nurse should implement when delivering emergent defibrillation. If not followed correctly, the patient and health care team may be placed in danger.

The nurse instructs Ms. Bailey to call the physician or hospital immediately with which one of the following signs and symptoms? a) Chest pain or shortness of breath b) Blood glucose of 180 1 hour after eating c) Open sores on toes d) Tension headaches

a) Chest pain or shortness of breath Explanation: Chest pain and shortness of breath are serious symptoms that should be reported immediately. Open sores on toes would be something Theresa should point out to her PCP on the follow-up visit next week. Blood glucose levels normally rise after a meal. Theresa can be instructed to treat tension headaches with rest and/or mild analgesics, such as Tylenol.

a) Creatinine kinase-myoglobin (CK-MB) level Explanation: Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. There are three isomers of troponin: C, I, and T. Troponin I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

Which of the following nursing measures are priorities for Mrs. Melnik? a) Daily weights b) Vital signs every shift c) Semi-Fowler's position d) Oxygen at 6 L by nasal catheter

a) Daily weights, c) Semi-Fowler's position, d) Oxygen at 6 L by nasal catheter Explanation: IV morphine decreases O2 demands and O2 administration helps increase the percentage of inspired air. Daily weights help monitor fluid gain/loss in the client experiencing or at risk for fluid volume overload. The client should be in high Fowler's position to help decrease venous return and to increase thoracic capacity. Vital signs should be assessed every hour to every 4 hours depending on client condition and medications being administered. As she is being given IV furosemide, she needs to be more frequently monitored for dehydration and circulatory collapse (BP and pulse).

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain? a) Description of the pain b) Pulse rate in upper extremities c) Blood pressure in the left arm d) Sound of the apical pulses

a) Description of the pain Explanation: If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.

Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply. a) Direct vasodilators may cause headache and tachycardia. b) With thiazide diuretics, monitor serum potassium levels. c) With ACE inhibitors, assess for bradycardia. d) Beta-blockers may cause sedation. e) With adrenergic inhibitors, cough is a common side effect.

a) Direct vasodilators may cause headache and tachycardia., b) With thiazide diuretics, monitor serum potassium levels. Explanation: Thiazide diuretics may deplete potassium; many clients will need potassium supplementation. Angiotensin-converting enzyme (ACE) inhibitors can induce a mild to severe dry cough. Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration. Direct vasodilators may cause headache and increased heart rate. Adrenergic inhibitors can cause sedation and fatigue.

The nurse is caring for a patient in the ICU diagnosed with coronary artery disease (CAD). Which of the following assessment data indicates the patient is experiencing a decrease in cardiac output? a) Disorientation, 20 mL of urine over the last 2 hours b) Elevated jugular venous distention (JVD) and postural changes in BP c) BP 108/60 mm Hg, ascites, and crackles d) Reduced pulse pressure and heart murmur

a) Disorientation, 20 mL of urine over the last 2 hours Explanation: Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.

A patient with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The patient's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of which of the following? a) Embolic stroke b) Heart failure c) Myocardial infarction d) Renal failure

a) Embolic stroke Explanation: Intervention is implemented to prevent the development of an embolic event/stroke. Patients with a history of previous stroke, transient ischemic attack (TIA), embolic event, mitral stenosis, or prosthetic heart valve and who develop atrial fibrillation are at significant risk of developing an embolic stroke. Antithrombotic therapy is indicated for all patients with atrial fibrillation, especially those at risk of an embolic event, such as a stroke, and is the only therapy that decreases cardiovascular mortality. These patients are often placed on warfarin, in contrast to patients who have no risk factors, who are often prescribed 81 to 325 mg of aspirin daily.

Which of the following is the most important principle the nurse considers in planning post-MI patient education? a) Establish the patient's priorities and plan teaching around them. b) Warn the patient that he will have another MI if he does not make some lifestyle changes. c) Determine patient's current knowledge level. d) Use handouts because the patient will not retain information you give him.

a) Establish the patient's priorities and plan teaching around them. Explanation: Establishing and working with the patient's priorities will give him a sense of control and ensure an investment in making lifestyle changes. Issuing "threats" is not often successful in effecting lifestyle change. Determining the patient's current knowledge level is an important part of planning patient education, but determining the patient's priorities has a higher value in ensuring successful lifestyle changes. Handouts are an important tool in patient education, but determining the patient's priorities has a higher value in ensuring successful lifestyle changes.

Which of the following medications is categorized as a loop diuretic? a) Furosemide (Lasix) b) Spironolactone (Aldactone) c) Chlorthalidone (Hygroton) d) Chlorothiazide (Diuril)

a) Furosemide (Lasix) Explanation: Lasix is commonly used in the treatment of cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide is categorized as a thiazide diuretic. Chlorthalidone is categorized as a thiazide diuretic. Spironolactone is categorized as a potassium-sparing diuretic

The nurse notes that Ms. Anderson's K+ level is 6.0. What is the most likely cause for this? a) Hemolysis from the cardiopulmonary bypass machine b) K+ added to IV bag c) Inadequate fluid intake d) NG tube suctioning

a) Hemolysis from the cardiopulmonary bypass machine Explanation: The CPB can cause hemolysis. Lysis of the RBCs will release K+ from the intracellular space resulting in serum hyperkalemia. Excessive NG tube drainage would cause hypokalemia. While it is likely the IV potassium additive would be discontinued, this is not the most likely cause of the patient's hyperkalemia. Inadequate fluid intake would lead to hypokalemia.

Which of the following complications of hypertensive crisis is Mr. Easton exhibiting? a) Hypertensive encephalopathy b) Aortic dissection c) Renal insufficiency d) Rapid cardiac decompensation

a) Hypertensive encephalopathy Explanation: Hypertensive encephalopathy manifests as a sudden rise in BP and may be associated with headache, nausea/vomiting, confusion, seizures, stupor, and coma. Rapid cardiac decompensation may manifest as chest pain and dyspnea. Symptoms of renal insufficiency vary depending on severity. Aortic dissection may manifest as extreme chest and back pain, diaphoresis, and loss of pulses in extremities.

The nurse understands that asystole can be caused by several of the following. Select all that apply. a) Hypovolemia b) Acidosis c) Hypothermia d) Hypoxia e) Alkalosis

a) Hypovolemia, b) Acidosis, c) Hypothermia, d) Hypoxia Explanation: Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality cardiopulmonary resuscitation (CPR) with minimal interruptions and identifying underlying and contributing factors. The key to successful treatment is a rapid assessment to identify a possible cause, which is known as the "Hs and Ts": hypoxia, hypovolemia, hydrogen ion (acid/base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hyperthermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary).

The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following? a) If a dosage of medication is missed, double up on the next one to catch up. b) Do not stop antihypertensive medication abruptly. c) Avoid hot baths, exercise, and alcohol within 3 hours of taking vasodilators. d) Avoid over the counter (OTC) cold, weight reduction, and sinus medications.

a) If a dosage of medication is missed, double up on the next one to catch up. Explanation: Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Hot baths, strenuous exercise, and excessive alcohol are all vasodilators and should be avoided. Many OTC preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended.

Expected abnormalities in serum studies confirming angina include which of the following options? a) Increased CRP b) Increased myoglobin c) Decreased LDL d) Increased troponin

a) Increased CRP Explanation: Elevated CRP indicates inflammation; inflammation of the endothelium of the coronary arteries is a probable factor in the development of CAD; CAD is the primary cause of angina. Increased troponin and increased myoglobin indicate MI. LDL would likely be elevated in CAD.

Age-related changes associated with the cardiac system include which of the following? Select all that apply. a) Increased size of the left atrium b) Myocardial thinning c) Endocardial fibrosis d) Increase in the number of SA node cells

a) Increased size of the left atrium, c) Endocardial fibrosis Explanation: Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.

The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Partial thromboplastic time (PTT) c) Complete blood count (CBC) d) Sodium

a) International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin.

Why is the nurse concerned about Mr. Easton's complaint of blurry vision? a) It signals possible target organ damage. b) It indicates he has increased his alcohol intake. c) It is a sign of hydrocholorthiazide toxicity. d) It is not of concern; he simply needs new eye glasses.

a) It signals possible target organ damage. Explanation: Target organ damage is the most common complication of untreated/under treated HTN. Affected organ systems are the heart (CAD, LVH, and heart failure), the cerebrovascular system (cerebroatherosclerosis, stroke, and hypertensive encephalopathy), the peripheral vascular system, kidneys, and the eye (retinal damage). Blurry vision is not a side effect of HTCZ.

A nurse is assessing a patient with congestive heart failure for jugular vein distension (JVD). Which of the following observations is important to report to the physician? a) JVD is noted 3 cm above the sternal angle. b) JVD is noted at the level of the sternal angle. c) No JVD is present. d) JVD is noted 1 cm above the sternal angle.

a) JVD is noted 3 cm above the sternal angle. Explanation: JVD is assessed with the patient sitting at a 45° angle. Jugular vein distention greater than 3 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse? a) Left arm numbness and weakness b) Chest pain score of 3/10 (on a scale of 1 to 10) c) Urine output of 40 cc/mL over the last hour d) Nausea and severe headache

a) Left arm numbness and weakness Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions. A urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.

Administration of the fibrolytic agent alteplase includes certain tasks such as ECG and heart and lung assessments. Which of the following are the other expected tasks in nursing assessments and interventions during the administration of the fibrolytic agent alteplase? Select all that apply. a) Monitor for evidence of internal or external bleeding b) Assess neuro signs every 15 to 30 minutes c) Expect increase in chest pain as "clot buster" takes effect d) Expect spike in ST segment e) Expect reperfusion dysrhythmias

a) Monitor for evidence of internal or external bleeding, b) Assess neuro signs every 15 to 30 minutes, e) Expect reperfusion dysrhythmias Explanation: Altepase is a clot lysing agent that must be given within 6 hours of symptom onset (preferably within 1 hour). As hypotension and stroke are possible side effects, monitor neurologic and cardiovascular signs every 15 to 30 minutes. Other possible side effects are GI/GU bleeding and ecchymosis. All IV puncture sites require 30 minutes of manual pressure followed by a pressure dressing. Reperfusion dysrhythmias such as accelerated idioventricular rhythm or sinus bradycardia may occur, and are usually of short duration. Additional side effects include n/v and fever. The site of the lysed thrombus remains unstable, with the possibility of reocclusion of the affected artery; for this reason, patients will often also be on IV heparin to prevent clot reformation. Patients should be on bedrest for 8 to 12 hours following an uncomplicated MI. Chest pain should abate, and ST elevation should return to near baseline level as the clot is dissolved and the affected area is reperfused.

Which of the following risk factors for CAD does Ms. Bailey present with? a) Obesity b) Diabetes mellitus c) Bradycardia d) Stressful lifestyle e) Hypertension

a) Obesity, b) Diabetes mellitus, e) Hypertension Explanation: There is a strong correlation between obesity as a risk factor and the development of CAD. Ms. Bailey has a body mass index (BMI) of 41, which is considered obese. Any BMI over 25 is considered overweight. There is a strong correlation between diabetes and the development of CAD. Hyperglycemia contributes to dyslipidemia and platelet aggregation, which can lead to thrombus formation. There is a strong correlation between HTN and the development of CAD. HTN contributes to the stiffness of vessel walls, vessel wall injury, and inflammation. Bradycardia is not considered a risk factor for the development of CAD. Theresa has not suggested that her lifestyle is stressful.

The nurse is caring for a patient with clubbing of the fingers and toes. The nurse should complete which of the following actions given these findings? a) Obtain an oxygen saturation level. b) Assess the patient for pitting edema. c) Obtain a 12-lead ECG tracing. d) Assess the patient's capillary refill.

a) Obtain an oxygen saturation level. Explanation: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the patient's O2 saturation level and intervene as directed. The other assessments are not indicated.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough b) Weight loss c) Ability to sleep through the night d) Increased appetite

a) Persistent cough Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.

a) Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel (Plavix) is an antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following? a) Pulmonary artery wedge pressure b) Central venous pressure c) Pulmonary artery pressure d) Cardiac output

a) Pulmonary artery wedge pressure Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems? a) Pulmonary embolism b) Pulmonary edema c) Myocardial infarction d) Pneumonia

a) Pulmonary embolism Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that risk factors and cardiovascular problems related to hypertension include which of the following? Select all that apply. a) Smoking b) Decreased low-density lipoprotein (LDL) levels. c) Elevated high-density lipoprotein (HDL) cholesterol d) Obesity (BMI ≥ 30 kg/m2) e) Age ≥55 in men

a) Smoking, d) Obesity (BMI ≥ 30 kg/m2), e) Age ≥55 in men Explanation: Major risk factors (in addition to hypotension) include smoking, dyslipidemia (high LDL, low HDL cholesterol), diabetes mellitus, impaired renal function, obesity, physical inactivity, age (older than 55 years for men, 65 years for women), and family history of cardiovascular disease.

9:02 A.M. You measured Mrs. Downs's blood pressure at 112/64. However, what if you measured Mrs. Downs's blood pressure at 162/94? She tells you she's never had high blood pressure and had normal readings in the hospital. What should you do in such a situation? a) Reassure Mrs. Downs and help her relax. b) Report the reading to her physician. c) Wait for 30 to 60 seconds and repeat the reading. d) Check the size of the cuff. e) Check that the cuff is not wrapped too loosely around her arm. f) Administer Mrs. Downs' medication to lower her pressure. g) Check the physician's order for the next scheduled assessment. h) Tell Mrs. Downs that her pressure is high because she's anxious.

a) Reassure Mrs. Downs and help her relax., b) Report the reading to her physician., c) Wait for 30 to 60 seconds and repeat the reading., d) Check the size of the cuff., e) Check that the cuff is not wrapped too loosely around her arm. Explanation: You must repeat the reading, waiting at least 30-60 seconds to allow normal circulation to return in her arm. Make sure to deflate the cuff completely between attempts. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings. Reassure Mrs. Downs and help her relax to make sure that she is not anxious, which could cause a false high reading. Check the size of the cuff. A cuff that's too small can cause a false high reading. Check that the cuff is not wrapped too loosely around her arm. Allow the cuff to deflate at a rate of 2-3 mm Hg per second to eliminate venous congestion in the arm. If the reading remains high, record your findings and interventions and report the reading to her physician.

Decreased pulse pressure reflects which of the following? a) Reduced stroke volume b) Reduced distensibility of the arteries c) Elevated stroke volume d) Tachycardia

a) Reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

The nurse is screening a patient prior to a magnetic resonance angiogram (MRA) of the heart. Which of the following actions should the nurse complete prior to the patient undergoing the procedure? Select all that apply. a) Remove the patient's Transderm Nitro patch. b) Offer the patient a headset to listen to music during the procedure. c) Sedate the patient prior to the procedure. d) Remove the patient's jewelry. e) Position the patient on his/her stomach for the procedure.

a) Remove the patient's Transderm Nitro patch., b) Offer the patient a headset to listen to music during the procedure., d) Remove the patient's jewelry. Explanation: Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A patient who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the patient is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Patients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the patient may be offered a headset to listen to music.

The nurse is caring for a patient prescribed Bumex (bumetanide) for the treatment of stage 2 hypertension. Which of the following indicates the patient is experiencing an adverse effect of the medication? a) Serum potassium value of 3.0 mEq/L b) Blood glucose value of 160 mg/dL c) Urine output of 90 cc/mL 1 hour after medication administration d) Electrocardiogram (EGG) tracing demonstrating peaked T waves

a) Serum potassium value of 3.0 mEq/L Explanation: Bumex is a loop diuretic that can cause fluid and electrolyte imbalances. Patients taking these medications may experience a low serum potassium level. ECG changes associated with an elevated serum potassium levels include peaked T waves. Diuresis is a desired effect postadministration of Bumex. The serum glucose level is elevated and requires intervention; however, this elevation is not associated with the administration of Bumex.

What should the nurse include in the education for the client taking simvastatin (Zocor)? a) Report muscle pain or weakness. b) It is not necessary to adhere to a low cholesterol diet while on statins. c) Take with grapefruit juice to enhance effectiveness. d) Dark urine is an expected side effect.

a) Report muscle pain or weakness. Explanation: Rhabdomyolysis, the destruction of muscle cells, is a serious potential side effect of statins. Symptoms include muscle pain, tenderness, and weakness, and darkening of the urine from the protein myoglobin. Grapefruit juice increases the serum level of many drugs. A low-cholesterol diet is still necessary, even while on statins.

The nurse is caring for a client who has developed junctional tachycardia with a heart rate (HR) of 80 bpm. Which of the following actions should the nurse complete? a) Request a digoxin level be ordered. b) Prepare to administer IV lidocaine. c) Prepare for emergent electrical cardioversion. d) Withhold the patient's oral potassium supplement.

a) Request a digoxin level be ordered. Explanation: The nurse should request a digoxin level be obtained. Junctional tachycardia generally does not have any detrimental hemodynamic effect; it may indicate a serious underlying condition, such as digitalis toxicity, myocardial ischemia, hypokalemia, or chronic obstructive pulmonary disease (COPD). Potassium supplements do not cause junctional tachycardia. Lidocaine is indicated for the treatment of premature ventricular contractions (PVCs). Because junctional tachycardia is caused by increased automaticity, cardioversion is not an effective treatment; in fact, it causes an increase in ventricular rate.

Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply. a) Retinal damage b) Diabetes c) Heart failure d) Stroke e) Hyperlipidemia

a) Retinal damage, c) Heart failure, d) Stroke Explanation: Target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. Hyperlipidemia and diabetes are risk factors for development of hypertension

hat clues suggest that Ms. Bailey has been noncompliant with her treatment plan? Select all that apply. a) Running out of medications without provisions for refills b) Complaints about the high cost of medications c) Comment about "watching her sugar" in her diet d) Report of monitoring her glucose daily at home

a) Running out of medications without provisions for refills, b) Complaints about the high cost of medications Explanation: The inability to pay for a medication often leads to non-compliance. The nurse should assess Theresa's finances and insurance, and her ability to pay for medications. The patient admitted to running out of medication and has not made the necessary appointment for a refill. The nurse should discuss the reasons for not following-up. The nurse needs to clarify the meaning of 'watching her sugar' before assuming non-compliance, and then assess for understanding of the diabetic diet. The patient states she has her BG checked at the clinic. The nurse should verify the treatment plan and determine if home blood glucose monitoring was part of her treatment plan.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? a) Spironolactone (Aldactone) b) Bumetanide (Bumex) c) Chlorothiazide (Diuril) d) Ethacrynic acid (Edecrin)

a) Spironolactone (Aldactone) Explanation: Aldactone is a potassium-sparing diuretic. A thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics

The nurse is caring for a client who is prescribed diuretic medication for the treatment of hypertension. The nurse recognizes that which of the following medications conserves potassium? a) Spironolactone (Aldactone) b) Chlorthalidone (Hygroton) c) Chlorothiazide (Diuril) d) Furosemide (Lasix)

a) Spironolactone (Aldactone) Explanation: Aldactone is known as a potassium-sparing diuretic. Lasix causes loss of potassium from the body. Diuril causes mild hypokalemia. Hygroton causes mild hypokalemia.

A 26-year-old male patient, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is being treated in the emergency department. The patient is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the patient becomes lightheaded but does not lose consciousness. Which of the following maneuvers may be used to interrupt the patient's atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply. a) Stimulating the patient's gag reflex b) Instructing the patient to vigorously exercise c) Performing carotid massage. d) Placing the patient's face in cold water e) Instructing the patient to breathe deeply

a) Stimulating the patient's gag reflex, c) Performing carotid massage., d) Placing the patient's face in cold water Explanation: The following vagal maneuvers can be used to interrupt AVNRT: stimulating the patient's gag reflex, having the patient hold his breath, cough, bear down, placing his face in cold water, or performing carotid massage. These measures elicit a vagal response which will slow AV conduction time and help restore a regular rhythm. Because of the risk of a cerebral embolic event, carotid massage is contraindicated in patients with carotid bruits. If the vagal maneuvers are ineffective, the patient may receive a bolus of adenosine to correct the rhythm; this is nearly 100% effective in terminating AVNRT. Overexertion and deep inspirations are measures that could precipitate SVT.

The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension? a) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm b) Supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm c) Supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm d) Supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm

a) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm Explanation: Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position. The following is an example of BP and HR measurements in a patient with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.

Which of the following statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. a) The patient's arm should be positioned at the level of the heart. b) Using a BP cuff that is too small will give a higher BP measurement. c) Using a BP cuff that is too large will give a higher BP measurement. d) The patient's BP should be taken 1 hour after the consumption of alcohol. e) Ask the patient to sit quietly while the BP is being measured.

a) The patient's arm should be positioned at the level of the heart., b) Using a BP cuff that is too small will give a higher BP measurement., e) Ask the patient to sit quietly while the BP is being measured. Explanation: These statements are all true when measuring a BP. When using a BP cuff that is too large the reading will be lower than the actual BP. The patient should avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is measured.

The nurse understands that an overall goal of hypertension management includes which of the following? a) There is no indication of target organ damage. b) There are no complaints of sexual dysfunction. c) There is no complaint of postural hypotension. d) The patient maintains a normal blood pressure reading.

a) There is no indication of target organ damage. Explanation: Prolonged blood pressure elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. The overall goal of management is that the patient does not experience target organ damage. The desired effects of antihypertensives are to maintain a normal BP. Postural hypotension and sexual dysfunction are side effects of certain antihypertension medications.

What is the purpose of the patient's cardiac catheterization procedure? a) To determine the extent of atherosclerosis and coronary artery patency b) To assess cardiac dysrhythmias c) To assess blood return to the right side of the heart and right ventricular function d) To determine if he has left ventricular hypertrophy (LVF)

a) To determine the extent of atherosclerosis and coronary artery patency Explanation: Radiopaque catheters are inserted into specific areas of the heart (cardiac cath) and a contrast media injected (arteriography) to assess coronary artery patency and the degree of atherosclerosis. LVF is diagnosed by cardiac imaging studies. Central venous pressure (CVP) monitoring is performed to assess blood return to the right side of the heart and right ventricular function. Dysrhythmias are assessed using ECG or electrophysiologic testing (EPS).

What is the reason Mrs. Melnik is being started on warfarin (Coumadin)? a) To prevent atrial fibrillation from forming thrombus in the atria b) To increase ejection fraction c) To prevent deep vein thrombosis (DVT) related to her increasing fatigue d) To increase cardiac output

a) To prevent atrial fibrillation from forming thrombus in the atria Explanation: Warfarin is an anticoagulant used to prevent thrombus formation. Mrs. Melnick is at risk for atrial thrombus formation related to atrial fibrillation. She will require close lab monitoring; her INR should be 2 to 3 to be therapeutic.

Which of the following nursing interventions should a nurse perform when a patient with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta blockers? a) Withhold the drug and inform the primary health care provider. b) Observe for symptoms of pulmonary edema. c) Check for signs of toxicity. d) Continue the drug and document in the patient's chart.

a) Withhold the drug and inform the primary health care provider. Explanation: Before administering beta blockers, the nurse should monitor the patient's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.

Chest pain or discomfort not relieved by rest or nitroglycerin is associated with

acute MI.

The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same patient for

acute MI.

IV morphine is the analgesic of choice for treatment of an

acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart.

A patient presents to the emergency room complaining of chest pain the priority is to determine if the patient is suffering

an acute MI and implement appropriate interventions as quickly as possible.

An abnormal Q wave may be present without ST-segment and T-wave changes, which indicates

an old, not acute, MI.

An immediate objective of rehabilitation of the MI patient is to limit the effects and progression of

atherosclerosis.

The nurse is caring for patient experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase (Activase). Prior to administering this medication, which of the following questions is most important for the nurse to ask the patient? a) "Do your parents have a history of heart disease?" b) "What time did your chest pain start today?" c) "How many sublingual nitroglycerin tabs did you take?" d) "What is your pain level on a scale of 1 to 10?"

b) "What time did your chest pain start today?" Explanation: The patient may be a candidate for thrombolytic (fibrolytic) therapy. These medications are administered if the patient's chest pain lasts longer than 20 minutes, unrelieved by nitroglycerin, ST-segment elevation in the at least two leads that face the same area of the heart, less than 6 hours from onset of pain. The most appropriate question for the nurse to ask is in relationship to when the chest pain began. The other questions would not aid in determining if the patient is a candidate for thrombolytic therapy.

A 77-year-old woman presents to the local community center for a blood pressure screening. The women's blood pressure is recorded as 180/90 mm Hg. The woman has a history of hypertension, but she currently is not taking her medications. Which of the following questions is most appropriate for the nurse to ask the patient first? a) "What medications are you prescribed?" b) "Why is it that you are not taking your medications?" c) "Are you having trouble paying for your medication?" d) "Are you able to get to your pharmacy to pick up your medications?"

b) "Why is it that you are not taking your medications?" Explanation: It is important for the nurse to first ascertain if the reason why the patient is not taking her medications. Adherence to the therapeutic program may be more difficult for older adults. The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. The other questions are appropriate, but the priority is to determine why the medication regimen is not being followed.

The nurse is caring for a 56-year-old male patient who had an implantable cardioverter defibrillator (ICD) implanted 2 days prior. The patient tells the nurse "My wife and I can never have sex again now that I have this ICD." The nurse's best response is which of the following? a) "I will be sure to share your concerns with the physician." b) "You seem apprehensive about resuming sexual activity." c) "Sex is permitted following the implantation of an ICD." d) "You really should speak to your wife about your concerns."

b) "You seem apprehensive about resuming sexual activity." Explanation: The patient treated with an electronic device experiences not only lifestyle and physical changes but also emotional changes. At different times during the healing process, the patient may feel angry, depressed, fearful, anxious, or a combination of these emotions. It is imperative for the nurse to observe the patient's response to the device and provide the patient and family members with emotional support and teaching as indicated. Identifying that the patient appears apprehensive about resuming sexual activity acknowledges the patient's concerns while allowing for further discussion. The remaining responses ignore the patient's feelings and do not facilitate an ongoing conversation or explore the patient's concern.

Based on the information given, what do you think the admitting nurse suspects Mrs. Melnik to be experiencing? a) Myocardial infarction b) Acute decompensated heart failure c) Pneumonia d) Hypertensive crisis

b) Acute decompensated heart failure Explanation: The primary manifestation of ADHF is pulmonary edema, most commonly due to left ventricular failure. The client typically presents as anxious and pale (possibly cyanotic), with cold, clammy skin. Severe dyspnea is often present with a respiratory rate greater than 30 and tachycardia. BP may be elevated or decreased, depending on the severity of the HF. There may be orthopnea, adventitious lung sounds, and cough productive of frothy and/or blood-tinged sputum. Mrs. Melnik's WBC is within normal limits. Given her previous diagnosis of HF and the worsening of her LVH, her pulmonary symptoms are most likely due to ADHF, not a respiratory illness such as pneumonia. Hypertensive crisis includes a diastolic BP greater than 140 mm Hg. The patient is not exhibiting signs and symptoms associated with myocardial infarction.

A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention? a) Administer angiotensin-converting enzyme inhibitors b) Assess oxygen saturation level c) Administer angiotensin II receptor blockers d) Administer diuretics

b) Assess oxygen saturation level Explanation: Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve patient symptoms and reduce the workload on the heart by reducing afterload and preload.

A patient's ECG tracing reveals a ventricular rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as which of the following? a) Ventricular fibrillation b) Atrial flutter c) Atrial fibrillation d) Ventricular tachycardia

b) Atrial flutter Explanation: The nurse correctly identifies the ECG tracing as atrial flutter. Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in appearance. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. The atrial rate is 300 to 600, and the ventricular rate is usually 120 to 200 in untreated atrial fibrillation. There are no discernible P waves. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. The ventricular rate is greater than 300 per minute and extremely irregular, without a specific pattern. The QRS shape and duration is irregular, undulating waves without recognizable QRS complexes. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per

A nurse is completing a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The patient's heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The patient is also experiencing dizziness and shortness of breath. Which of the following medications will the nurse anticipate administering to the patient based on these clinical findings? a) Cardizem b) Atropine c) Lidocaine d) Pronestyl

b) Atropine Explanation: The patient is demonstrating signs and symptoms of symptomatic sinus bradycardia. Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias

A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following? a) Request sublingual nitroglycerin. b) Avoid caffeinated beverages c) Lie down and elevate the feet. d) Apply supplemental oxygen

b) Avoid caffeinated beverages Explanation: If PACs are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.

A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next? a) Administer intravenous epinephrine. b) Begin cardiopulmonary resuscitation. c) Prepare for endotracheal intubation. d) Provide electrical cardioversion.

b) Begin cardiopulmonary resuscitation. Explanation: In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the patient as soon as possible. If defibrillation is not readily available, CPR is begun until the patient can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a patient in ventricular fibrillation.

A nurse is caring for a patient in the cardiovascular intensive care unit (CVICU) following a coronary artery bypass graft (CABG). Which of the following clinical findings requires immediate intervention by the nurse? a) Pain score: 5/10. b) CVP reading: 1 mmHg c) Blood pressure: 110/68 mmHg d) Heart rate: 66 bpm

b) CVP reading: 1 mmHg Explanation: The central venous pressure (CVP) reading of 1 is low (2-6 mmHg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.

9:02 A.M. Your reassurance has made Mrs. Downs feel a little better. It's important to include interventions to prevent infection in your care. What steps will you take to break the chain of infection when assessing Mrs. Downs' blood pressure? a) Maintain surgical asepsis. b) Cleanse the equipment with an alcohol swab. c) Put on gown. d) Put on goggles and mask. e) Perform hand hygiene. f) Put on clean gloves. g) Put on sterile gloves.

b) Cleanse the equipment with an alcohol swab., e) Perform hand hygiene. Explanation: You must perform hand hygiene. You must also clean your equipment with an alcohol swab, specifically the diaphragm or bell of the stethoscope, depending on which side you are going to use. Also, clean the earpieces with a second swab if the stethoscope is not yours. This deters the spread of microorganisms. You usually do not need to put on gloves, a gown, goggles, or mask, or maintain surgical asepsis for assessing Mrs. Downs' blood pressure.

The nurse is preparing to apply ECG electrodes to a male patient who requires continuous cardiac monitoring. Which of the following should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? a) Clean the patient's chest with alcohol prior to application of the electrodes. b) Clip the patient's chest hair prior to applying the electrodes. c) Apply baby powder to the patient's chest prior to placing the electrodes. d) Once the electrodes are applied, change them every 72 hours.

b) Clip the patient's chest hair prior to applying the electrodes. Explanation: The nurse should complete the following actions when applying cardiac electrodes: Clip (do not shave) hair from around the electrode site, if needed; if the patient is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). Change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); examine the skin for irritation and apply the electrodes to different locations.

The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following? a) Diastole b) Contractility c) Depolarization d) Repolarization

b) Contractility Explanation: Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.

A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems? a) Acute exacerbation of chronic obstructive pulmonary disease b) Decompensated heart failure with pulmonary edema c) Tuberculosis d) Bilateral pneumonia

b) Decompensated heart failure with pulmonary edema Explanation: Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated HF with pulmonary edema.

A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following? a) Decreases cholesterol level b) Decreases resting heart rate c) Decreases platelet aggregation d) Increases cardiac output

b) Decreases resting heart rate Explanation: The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. Generally the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

Which of the following does Mrs. Melnick's diagnostic test results indicate? a) Renal failure b) Diastolic heart failure c) Decreased ejection fraction d) Systolic heart failure

b) Diastolic heart failure Explanation: Diastolic failure is marked by pulmonary congestion (evidenced by Mrs. Melnik's dyspnea, orthopnea, and edema), pulmonary hypertension, ventricular hypertrophy, and normal EF. Systolic failure is marked by a decreased LV EF. Mrs. Melnik's signs and symptoms and diagnostic tests do not indicate renal disease. Additionally, LVH is often seen in HF and her BNP indicates increased filling pressures. With LVH, changes in the heart's electrical system occur, resulting in dysrhythmias.

The nurse is caring for a patient newly diagnosed with coronary artery disease (CAD). While developing a teaching plan for the patient to address modifiable risk factors for CAD, the nurse will include which of the following? Select all that apply. a) Alcohol use b) Elevated blood pressure c) Drug use d) Obesity e) Decreased LDL level

b) Elevated blood pressure, d) Obesity Explanation: Hypertension, obesity, hyperlipidemia, tobacco use, diabetes mellitus, metabolic syndrome, and physical inactivity are modifiable risk factor for CAD. Alcohol and drug use are not included in the list of modifiable risk factors for CAD.

It is important for the nurse to encourage the patient diagnosed with hypertension to rise slowly from a sitting or lying position for which of the following reasons? a) Gradual changes in position help reduce the heart's work to resupply oxygen to the brain. b) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. c) Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the brain. d) Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain.

b) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. Explanation: It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain and not blood pressure or heart rate.

A patient with congestive heart failure is admitted to the hospital with complaints of shortness of breath. How should the nurse position the patient in order to decrease preload? a) Prone with legs elevated on pillows b) Head of the bed elevated at 45 degrees and lower arms supported by pillows c) Supine with arms elevated on pillows above the level of the heart d) Head of the bed elevated at 30 degrees and legs elevated on pillows

b) Head of the bed elevated at 45 degrees and lower arms supported by pillows Explanation: Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient's weight on the shoulder muscles.

The nurse is caring for a patient in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is most suggestive of which of the following? a) Ventricular hypertrophy b) Heart failure c) Pulmonary edema d) Myocardial infarction

b) Heart failure Explanation: A BNP level greater than 100 pg/mL is suggestive of HF. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the clinician correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF.

During the auscultation of a patient's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which of the following? a) Heart failure b) Hypertensive heart disease c) Diseased heart valves d) Turbulent blood flow

b) Hypertensive heart disease Explanation: Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves

A patient is being treated in the intensive care unit following an acute MI. During the nursing assessment, the patient states shortness of breath and chest pain. In addition, the patient's blood pressure (BP) is 100/60 mm Hg with a heart rate (HR) of 53 bpm, and the electrocardiogram (ECG) tracing shows more P waves than QRS complexes. Which of the following actions should the nurse complete first? a) Prepare for defibrillation. b) Initiate transcutaneous pacing. c) Administer 1 mg of IV atropine. d) Obtain a 12-lead ECG.

b) Initiate transcutaneous pacing. Explanation: The patient is experiencing a third-degree heart block. Transcutaneous pacing should be implemented first. A permanent pacemaker may be indicated if the block continues. Defibrillation is not indicated; third-degree heart block does not respond to atropine; a 12-lead ECG may be obtained, but is not completed first.

What expectation would the nurse have regarding Ms. Anderson's chest tube drainage? a) It will decrease to 0 mL within 24 hours. b) It will change in color to sanguinous to serosanguinous to serous. c) It will be 500 mL to 600 mL for the first 6 hours. d) It will be sanguinous with tissue shreds.

b) It will change in color to sanguinous to serosanguinous to serous. Explanation: Chest tube drainage should be no more than 200 mL for the first 6 hours; it would be expected to begin to decrease after this. It will be sanguinous at first, changing to serosanguinous, and to serous as the drainage amount decreases.

When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the healthy adult, which of the following is true? a) Pressures may vary 10 mm Hg or more between arms. b) Pressures should not differ more than 5 mm Hg between arms. c) Pressures may vary, with the higher pressure found in the left arm. d) Pressures must be equal in both arms.

b) Pressures should not differ more than 5 mm Hg between arms. Explanation: Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. The pressures in each arm do not have to be equal in order to be considered normal. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension? a) Acid-based imbalance b) Renal disease c) Calcium deficit d) Hepatic function

b) Renal disease Explanation: Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.

Which of the following findings indicates that hypertension is progressing to target organ damage? a) Chest x-ray showing pneumonia b) Retinal blood vessel damage c) Urine output of 60 cc/mL over 2 hours d) Blood urea nitrogen (BUN) level of 12 mg/dL

b) Retinal blood vessel damage Explanation: Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. A BUN level and 60 cc/mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

Hypertension that can be attributed to an underlying cause is termed which of the following? a) Essential b) Secondary c) Isolated systolic d) Primary

b) Secondary Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma). Primary hypertension has no known underlying cause. Essential hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

The nurse is caring for a patient with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which of the following questions? a) "When was the last time you ate or drank?" b) "Are you having chest pain?" c) "Are you allergic to shellfish?" d) "What was your morning blood sugar reading?"

c) "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the patient is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the patient has a suspected or known allergy to the substance, antihistamines or methylprednisolone (Solu-Medrol) may be administered before the procedure. Although the other questions are important to ask the patient, it is most important to ascertain if the patient has an allergy to shellfish.

The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective? a) "After taking two tablets with no relief, I should call emergency medical services." b) "I can put the nitroglycerin tablets in my daily pill dispenser with my other medications". c) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". d) "Side effects of nitroglycerin include, flushing, throbbing headache, and hypertension".

c) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". Explanation: Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin includes: flushing, throbbing headache, hypotension, and tachycardia.

The nurse is caring for a patient newly diagnosed with hypertension. Which of the following statements if made by the patient indicates the need for further teaching? a) "I will consult a dietician to help get my weight under control." b) "I think I'm going to sign up for a yoga class twice a week to help reduce my stress." c) "If I take my blood pressure and it is normal, I don't have to take my BP pills." d) "When getting up from bed, I will sit for a short period prior to standing up."

c) "If I take my blood pressure and it is normal, I don't have to take my BP pills." Explanation: The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. The patient must take his/her medication as directed. A normal BP indicates the medication is producing its desired effect. The other responses do not indicate the need for further teaching.

The nurse is caring for a patient with systolic blood pressure of 135 mm Hg. This finding would be classified as which of the following? a) Normal b) Stage 1 hypertension c) Prehypertension d) Stage 2 hypertension

c) Prehypertension Explanation: A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. A systolic BP of greater than or equal to 160 is classified as stage II hypertension.

The nurse is caring for a female client who has had 25 mg of oral hydrochlorothiazide added to her medication regimen for the treatment of hypertension (HTN). Which of the following instructions should the nurse give the patient? a) "You may develop dry mouth or nasal congestion while on this medication." b) "Take this medication before going to bed." c) "Increase the amount of fruits and vegetables you eat." d) "You may drink alcohol while taking this medication."

c) "Increase the amount of fruits and vegetables you eat." Explanation: Thiazide diuretics cause loss of sodium, potassium, and magnesium. The patient should be encouraged to eat fruits and vegetables which are high in potassium. Diuretics cause increased urination; the patient should not take the medication prior to going to bed. Thiazide diuretics to not cause dry mouth or nasal congestion. Postural hypotension (side effect) may be potentiated by alcohol.

How will you respond to the patient's concerns about his ED? a) "It's not from your antihypertensive, it's a normal aging change." b) "You have to take your BP medication, so I guess you'll have to learn to live with this." c) "Let's talk to your doctor about switching to a drug that does not have this side effect." d) "All antihypertensives have this side effect."

c) "Let's talk to your doctor about switching to a drug that does not have this side effect." Explanation: Some classes of antihypertensives (including thiazides and beta-blockers) can cause sexual dysfunction, including ED, loss of libido, and decreased ejaculation. There are other classes Mr. Easton could try that do not have this potential side effect.

A 55-year-old man newly diagnosed with hypertension returns to his physician's office for a routine follow-up appointment after several months of treatment with Lopressor (metoprolol). During the nurse's initial assessment the patient's blood pressure (BP) is recorded as 180/90 mm Hg. The patient states he does not take his medication as prescribed. The best response by the nurse is which of the following? a) "It is very important for you to take your medication as prescribed, or you could experience a stroke." b) "Be certain to discuss your noncompliance with your medication regimen with the physician." c) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" d) "Your hypertension must be treated with medications; you need to take your Lopressor every day."

c) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" Explanation: The nurse needs to understand why the patient is not taking his medication. Lopressor is a beta-blocker. All patients should be informed that beta-blockers might cause sexual dysfunction and that other medications are available if problems with sexual function occur. The other statements, although true, are nontherapeutic and would not elicit why the patient was not taking his medications as prescribed.

c) 60 minutes Explanation: The 60-minute interval is known as "door-to-balloon time" for performance of PTCA on a diagnosed MI patient. The 30-minute interval is known as "door-to-needle time" for administration of thrombolytics post MI. The time frame of 9 days refers to the time for onset of vasculitis after administration of streptokinase for thrombolysis in an acute MI patient. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same patient for acute MI.

The nurse is assigned to care for the following patients admitted to a telemetry unit. Which patient should the nurse assess first? a) A patient returned from an electrophysiology (EP) procedure 2 hours ago complaining of constipation b) A patient diagnosed with new onset of atrial fibrillation requiring scheduled IV Cardizem c) A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV d) A patient who received elective cardioversion 1 hour ago with a heart rate (HR) is 115 bpm

c) A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV Explanation: The patient's ICD that has fired on the previous shift should be seen first. This patient is in need of antidysrhythmic medication and this is the priority intervention. The remaining patients should be seen after this patient and are in no acute distress.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the following patient findings requires immediate intervention by the nurse? a) Chest pain: 2 of 10 (1-to-10 pain scale) b) Presence of reperfusion dysrhythmias c) Altered level of consciousness d) Minimal oozing of blood from the IV site

c) Altered level of consciousness Explanation: A patient receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low, and indicates the patient's chest pain is subsiding, an expected outcome of this therapy.

The nurse is caring for a patient diagnosed with unstable angina receiving IV heparin. The patient is placed on bleeding precautions. Bleeding precautions include which of the following measures? a) Avoiding the use of nail clippers b) Avoiding continuous BP monitoring c) Avoiding subcutaneous (SQ) injections d) Using an electric toothbrush

c) Avoiding continuous BP monitoring Explanation: The patient receiving heparin is placed on bleeding precautions, which can include: applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or constrictive devices (e.g. continuous use of an automatic BP cuff). SQ injections are permitted; a soft toothbrush should be used, and the patient may use nail clippers, but with caution.

The nurse is caring for a patient with an intra-arterial BP monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which of the following? a) Air embolism b) Hemorrhage c) Catheter-related bloodstream infections (CRBSI) d) Pneumothorax

c) Catheter-related bloodstream infections (CRBSI) Explanation: CRBSIs are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.

The nurse is administering medications on a medical surgical unit. A patient is ordered to receive 40 mg of oral Corgard (nadolol) for the treatment of hypertension. Prior to administering the medication, the nurse should complete which of the following? a) Checking the patient's serum K+ level b) Weighing the patient c) Checking the patient's heart rate d) Checking the patient's urine output

c) Checking the patient's heart rate Explanation: Corgard is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP). The nurse should check the patient's heart rate (HR) prior to administering Corgard to ensure that the patient's pulse rate is not below 60 (beats per minute (bpm). The other interventions are not indicated prior to administering a beta-blocker medication.

A middle-aged male presents to the ED complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible MI? a) Anxiousness, restlessness, and lightheadedness b) Intermittent nausea and emesis for 3 days c) Chest discomfort not relieved by rest or nitroglycerin d) Cool, clammy, diaphoretic, and pale appearance

c) Chest discomfort not relieved by rest or nitroglycerin Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with ACS (acute coronary syndrome) or MI, may also occur with angina and, alone, are not indicative of an MI.

A nurse is evaluating a client with a temporary pacemaker. The patient's ECG tracing shows each P wave followed by the pacing spike. The nurse's best response is which of the following? a) Obtain a 12-lead ECG and a portable chest x-ray. b) Check the security of all connections and increase the milliamperage. c) Document the findings and continue to monitor the patient. d) Reposition the extremity and turn the patient to left side

c) Document the findings and continue to monitor the patient. Explanation: Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the patient. Repositioning the patient, placing the patient on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

An anterior wall MI indicates occlusion of which of the following coronary arteries? a) Aorta b) Circumflex artery c) Left anterior descending artery d) Right coronary artery

c) Left anterior descending artery Explanation: Anterior wall infarctions involve occlusion of the left anterior artery and show ST elevations in V2--V4. Circumflex artery occlusions cause lateral wall infarctions with ST elevations in V5--V6, I, and aVL and inferior wall infarctions with ST elevations in II, III, aVF. Occlusion of the right coronary artery would result in an inferior wall infarction showing ST elevations in leads II, III, and aVF. The aorta is not a coronary artery.

The nurse is analyzing the electrocardiogram (ECG) strip of a stable patient admitted to the telemetry unit. The patient's ECG strip demonstrates PR intervals that measure 0.24 seconds. Which of the following is the nurse's most appropriate action? a) Apply oxygen via nasal cannula and obtain a 12-lead ECG. b) Instruct the patient to bear down as if having a bowel movement. c) Document the findings and continue to monitor the patient. d) Notify the patient's primary care provider of the findings.

c) Document the findings and continue to monitor the patient. Explanation: The patient's ECG tracing indicates a first-degree atrioventricular (AV) block. First-degree AV block rarely causes any hemodynamic effect; the other blocks may result in decreased heart rate, causing a decrease in perfusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. The most appropriate action by the nurse is to document the findings and continue to monitor the patient.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) Blood urea nitrogen (BUN) b) Serum electrolytes c) Echocardiogram d) Electrocardiogram (ECG)

c) Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup

Due to which of the following factors is depression stated as a risk factor in the development or worsening of CAD? a) Depressed sympathetic nervous system b) Side effects of antidepressant drugs c) Elevated catecholamine levels d) Elevated homocysteine level

c) Elevated catecholamine levels Explanation: Elevated catecholemines, present in stressful states, can contribute to endothelial damage and inflammation and to platelet activation. Platelets play a role in the formation of athlerosclerotic plaques, which adhere more readily to a damaged endothelium. The sympathetic nervous system is stimulated, not depressed, in stressful states, leading to the release of catecholemines. Elevated homocysteine levels may be a risk factor in CAD development. However, elevation of this amino acid results from the breakdown of protein and not from depression. Antidepressant drug use does not lead to development of CAD.

The area of the heart that is located at the third intercostal (IC) space to the left of the sternum is which of the following? a) Pulmonic area b) Epigastric area c) Erb's point d) Aortic area

c) Erb's point Explanation: Erb's point is located at the third IC space to the left of the sternum. The aortic area is located at the second IC space to the right of the sternum. The pulmonic area is at the second IC space to the left of the sternum. The epigastric area is located below the xiphoid process.

c) IV morphine Explanation: IV morphine is the analgesic of choice for treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of Tenormin and Norvasc are not indicated in this situation.

The nurse auscultates the PMI (point of maximal impulse) at which of the following anatomic locations? a) Midsternum b) 1 inch to the left of the xiphoid process c) Left midclavicular line, fifth intercostal space d) 2 inches to the left of the lower end of the sternum

c) Left midclavicular line, fifth intercostal space Explanation: The left ventricle is responsible for the apical impulse or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the PMI is inappropriate based on variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI.

A nurse is preparing to assess a patient for postural BP changes. Which of the following indicates the need for further education? a) Positioning the patient supine for 10 minutes prior to taking the initial BP and HR b) Taking the patient's BP with the patient sitting on the edge of the bed with feet dangling c) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) d) Obtaining the supine measurements prior to the sitting and standing measurements

c) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) Explanation: The following steps are recommended when assessing patients for postural hypotension: Position the patient supine for 10 minutes before taking the initial BP and HR measurements; reposition the patient to a sitting position with legs in the dependent position, wait 2 minutes then reassess both BP and HR measurements; if the patient is symptom free or has no significant decreases in systolic or diastolic BP, assist the patient into a standing position, obtain measurements immediately and recheck in 2 minutes; continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the patient to supine position if postural hypotension is detected or if the patient becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompany the postural changes.

Which of the following is the hallmark of systolic heart failure? a) Low ejection fraction (EF) b) Pulmonary congestion c) Basilar crackles d) Limitation of activities of daily living (ADLs)

c) Low ejection fraction (EF) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient's symptoms

Which of the following assessments does the nurse need to perform on Mr. Easton? a) Monitor urine output every 4 hours b) Monitor neuro signs once a shift c) Monitor BP every 2 to 3 minutes during initial administration of sodium nitroprusside d) Get patient up to the commode to void

c) Monitor BP every 2 to 3 minutes during initial administration of sodium nitroprusside Explanation: Lowering BP more than 25% in the first hour could lead to stroke, MI, or renal failure. Urine output should be monitored hourly until stable to assess for renal function. The patient should remain on bedrest until stable. Neurologic signs should be monitored at least hourly until stable

c) Nitroglycerin SL Explanation: Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired and the nurse should anticipate administering nitroglycerin to assess if the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the patient's chest pain.

A patient admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which of the following electrocardiographic (ECG) characteristics is commonly associated with this laboratory finding? a) Occasional U waves b) Flattened P waves c) Peaked T waves d) Prolonged QT interval

c) Peaked T waves Explanation: The patient's serum potassium level is high. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a patient's serum potassium level is high. The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a patient's serum potassium level is low. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria and is not affected by a patient's serum potassium level. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization, and is not affected by a patient's serum potassium level.

Which of the following statements about cardiac stress tests with thallium-201 (201ΤΙ ), confirming a diagnosis of angina, is true? a) The patient will continue the stress test for 1 minute after the onset of pain. b) The patient will be on radioactive precautions for 24 hours. c) Perfusion is restored to ischemic areas within 3 hours. d) 201ΤΙ is taken up by ischemic cardiac tissue.

c) Perfusion is restored to ischemic areas within 3 hours. Explanation: 201ΤΙ is not taken up by ischemic cardiac tissue, and shows as "cold spots" on imaging. 201ΤΙ will move into the ischemic tissue (shows as "hot spots") indicating reperfusion of the area if the patient experienced angina ischemia during the stress test. Unresolved "cold spots" indicate probable MI. 201ΤΙ involves no more radiation than a normal x-ray study. Cardiac stress testing is interrupted and stopped if the patient experiences pain, extreme fatigue, has drops in BP or pulse, or has S-T segment changes or dysrhythmias on her continuous ECG.

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient? a) Enlargement of joints b) Vasculitis c) Potassium levels d) Flexion contractures

c) Potassium levels Explanation: A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

The nurse is caring for a patient presenting to the emergency department (ED) complaining of chest pain. Which of the following electrocardiographic (ECG) findings would be most concerning to the nurse? a) Frequent premature atrial contractions (PACs) b) Isolated premature ventricular contractions (PVCs) c) ST elevations d) Sinus tachycardia

c) ST elevations Explanation: The first signs of an acute MI are usually seen in the T wave and ST segment. The T wave becomes inverted; the ST segment elevates (usually flat). An elevation in ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e. ST elevation myocardial infarction, STEMI). This patient requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

9:03 A.M. Your assessment reveals a PICC in the left upper arm, making it necessary to take the measurement in Mrs. Downs's right arm. She's somewhat anxious about her current situation and learning a new skill. This could elevate her blood pressure. Mrs. Downs is a new patient, so a baseline reading is not available. Now you should assist Mrs. Downs to an appropriate position for the measurement of blood pressure. Can you identity the appropriate position to which you must assist Mrs. Downs for the blood pressure measurement? a) Lying down with her right arm raised , fist clenched. b) Sitting with her right forearm at the level of her heart, fist clenched. c) Sitting with her right forearm at the level of her heart, palm upward. d) Sitting up with her right arm held loosely by her side. e) Lying down with her right arm by her side, palm down.

c) Sitting with her right forearm at the level of her heart, palm upward. Explanation: You should assist Mrs. Downs to a sitting position with her right arm exposed and placed in a comfortable position. Her forearm should be supported at the level of her heart and her palm facing upward. This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily.

Prior to his discharge, Mr. Gruppman has a low-level treadmill test without evidence of ischemia. Based on this result, what information should he be given about his target heart rate during physical activity? a) His heart rate may exceed the target heart rate due to his atenolol. b) He should aim for 100% of his age-related heart rate while exercising. c) The most important factor to consider is his symptoms in response to activity. d) Isometric exercises would be better for him than isotonic exercises.

c) The most important factor to consider is his symptoms in response to activity. Explanation: Mr. Gruppman should be taught his exercise parameters and target heart rate; however, he should also be taught to "listen to his body" and stop if angina or dyspnea occurs. Beta-blockers slow heart rate, so Mr. Gruppman may not be able to reach a target heart rate. Isometric exercises rapidly increase BP and HR and should be avoided. Healthy persons should aim for 60% to 80% of their age-related target heart rate. Post-MI patients may be instructed to aim for a lower rate.

c) Unstable Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment

The nurse is reevaluating a patient 2 hours following a percutaneous transluminal coronary angioplasty (PTCA) procedure. Which of the following assessment findings may indicate the patient is experiencing a complication of the procedure? a) Heart rate of 100 bpm b) Potassium level of 4.0 mE/qL c) Urine output of 40 mL d) Dried blood at the puncture site

c) Urine output of 40 mL Explanation: Complications that may occur following a PTCA include myocardial ischemia, bleeding and hematoma formation, retroperitoneal hematoma, arterial occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and acute renal failure. The urine output of 40 mL over a 2-hour period may indicate acute renal failure. The patient is expected to have a minimum urine output of 30 mL per hour. Dried blood at the insertion site is a finding warranting no acute intervention. A serum potassium level of 4.0 mEq/L is within normal range. The heart rate of 100 bmp is within the normal range and indicates no acute distress.

Troponin I and T are specific for

cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury.

A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first? a) Troponin level b) Oxygen 2 liters nasal cannula c) Aspirin 325 mg orally d) 12-lead ECG

d) 12-lead ECG Explanation: The nurse should complete the 12-lead ECG first. The priority is to determine if the patient is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.

A patient is admitted to the emergency department (ED) with complaints of chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph (ECG) monitor. The nurse counts 9 RR intervals on the patient's 6-second rhythm tracing. The nurse correctly identifies the patient's heart rate as which of the following? a) 100 bpm b) 70 bpm c) 80 bpm d) 90 bpm

d) 90 bpm Explanation: An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. In this instance, 9 × 10 = 90.

Mr. Kingsolver asks the nurse to explain the results of his cholesterol tests to him and tell him what he can do to improve them. What should the nurse's appropriate response be? a) LDL is the "good" cholesterol and HDL is the "bad" cholesterol. b) Exercise has no effect on lipid levels. c) A diet high in carbohydrates will help lower triglyceride levels. d) A high HDL is desirable because it helps clear the body of LDL.

d) A high HDL is desirable because it helps clear the body of LDL. Explanation: HDL ("good" cholesterol) transports LDL to the liver, where it is broken down and excreted. HDL should be greater than 40 mg/dL, ideally greater than 60 mg/dL. LDL ("bad" cholesterol) adheres to arterial endothelium, beginning the process of plaque formation and CAD; in a client at high risk for CAD, the LDL level should be less than 100 mg/dL. Triglycerides are produced from excess caloric intake (from any source) and contribute to heart disease; they should be less than 200 mg/dL. Increased physical activity has been shown to increase HDL and lower triglycerides. Total cholesterol should be below 200 mg/dL.

A patient is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which of the following interventions is necessary for the nurse to implement prior to the procedure? a) Administer anticoagulant therapy as prescribed prior to the procedure. b) Maintain the patient on NPO status for 8 hours prior to the procedure. c) Administer the prescribed digitalis to the patient before the scheduled procedure. d) Administer moderate sedation IV and analgesic medication as prescribed.

d) Administer moderate sedation IV and analgesic medication as prescribed. Explanation: Before an elective cardioversion, the patient should receive moderate sedation IV as well as an analgesic medication or anesthesia. In contrast, in emergent situations, the patient may not be premedicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. If the cardioversion is elective and the dysrhythmia has lasted longer than 48 hours, anticoagulation performed for a few weeks before cardioversion may be indicated. The patient is instructed not to eat or drink for at least 4 hours before the procedure.

The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)? a) Reduction in cardiac output b) Reduction in forward flow c) Accumulation of blood in the lungs d) Congestion in the peripheral tissues

d) Congestion in the peripheral tissues Explanation: Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.

A nurse is providing evening care for a patient wearing a continuous telemetry monitor. While the nurse is giving the patient a back rub, the patient's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response? a) Administer a pericardial thump. b) Call a code and obtain the crash cart. c) Call for assistance and begin CPR. d) Assess the patient and monitor leads

d) Assess the patient and monitor leads. Explanation: The nurse should assess the patient and monitor leads first. It is important that the nurse "treat the patient, not the monitor." Ventricular asystole may often appear on the monitor when leads are displaced. The other interventions are not necessary.

The nurse understands that a patient with which cardiac arrhythmia is most at risk for developing heart failure? a) Sinus tachycardia b) First-degree heart block c) Supraventricular tachycardia d) Atrial fibrillation

d) Atrial fibrillation Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result from HF; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following? a) Lie down and elevate the feet. b) Request sublingual nitroglycerin. c) Apply supplemental oxygen. d) Avoid caffeinated beverages.

d) Avoid caffeinated beverages. Explanation: If PACs are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.

The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation? a) By checking for cardiac dysrhythmias b) By hemodynamic monitoring c) By observing the patient for bleeding d) By checking peripheral pulses

d) By checking peripheral pulses Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the patient for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.

The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure? a) Pulmonary crackles b) Cough c) Jugular vein distention (JVD) d) Dyspnea

d) Jugular vein distention (JVD) Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure

The nurse assessing a patient with an exacerbation of heart failure identifies which of the following symptoms as a cerebrovascular manifestation of heart failure (HF)? a) Nocturia b) Ascites c) Tachycardia d) Dizziness

d) Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

To assess for peripheral edema, the nurse will examine which of the following areas of the body? a) Under the sacrum b) Lips, earlobes c) Upper arms d) Feet, ankles

d) Feet, ankles Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.

The nurse is caring for a patient in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the patient's CVP as 8 mm Hg. The nurse understands that this finding indicates the patient is experiencing which of the following? a) Excessive blood loss b) Overdiuresis c) Left-sided heart failure (HF) d) Hypervolemia

d) Hypervolemia Explanation: The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right ventricular preload, which is most often from hypovolemia.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? a) II b) I c) III d) IV

d) IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II there is a slight limitation of ADLs. In Class III there is marked limitation on ADLs.

A patient diagnosed with a myocardial infarction (MI) has begun an active rehabilitation program. The nurse recognizes an overall goal of rehabilitation for a patient who has had an MI includes which of the following? a) Limiting the effects and progression of atherosclerosis b) Returning the patient to work and a preillness lifestyle c) Prevention of another cardiac event d) Improvement of the quality of life

d) Improvement of the quality of life Explanation: Overall, cardiac rehabilitation is a complete program dedicated to extending and improving quality of life. An immediate objective of rehabilitation of the MI patient is to limit the effects and progression of atherosclerosis. An immediate objective of rehabilitation of the MI patient is to return the patient to work and a preillness lifestyle. An immediate objective of rehabilitation of the MI patient is to prevent another cardiac event.

The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension? a) Stop alcohol intake b) Reduce smoking to no more than four cigarettes per day c) Limit aerobic physical activity to 15 minutes, three times per week d) Maintain adequate dietary intake of fruits and vegetables

d) Maintain adequate dietary intake of fruits and vegetables Explanation: Guidelines include adopting the dietary approaches to stop hypertension (DASH) eating plan: consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat, dietary sodium reduction: reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride), and physical activity: engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week), Moderate alcohol consumption: limit consumption to no more than two drinks (eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight people. Tobacco: should be avoided because anyone with high blood pressure is already at increased risk for heart disease, and smoking amplifies this risk.

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? a) Encourage patient to ambulate in room b) Teach patient about safe home use of the medication c) Titrate milrinone rate slowly before discontinuing d) Monitor blood pressure frequently

d) Monitor blood pressure frequently Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to patients with severe HF, including patients who are waiting for a heart transplant. Because the drug causes vasodilation, the patient's blood pressure is monitored prior to administration since if the patient is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and following infusions of milrinone.

A nurse is teaching patients newly diagnosed with coronary heart disease (CHD) about their disease process and risk factors for heart failure. Which of the following problems can cause left-sided heart failure (HF)? a) Ineffective right ventricular contraction b) Pulmonary embolus c) Cystic fibrosis d) Myocardial ischemia

d) Myocardial ischemia Explanation: Myocardial dysfunction and HF can be caused by a number of conditions including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of patients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, the death of myocardial cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

The nurse is analyzing a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as which of the following? a) Sinus tachycardia b) First-degree atrioventricular (AV) block c) Junctional tachycardia d) Normal sinus rhythm

d) Normal sinus rhythm Explanation: The ECG tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following? a) Hyperpnea b) Dyspnea on exertion c) Paroxysmal nocturnal dyspnea d) Orthopnea

d) Orthopnea Explanation: Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler's position. Dyspnea on exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

The nurse recognizes that the treatment for a non-ST elevation myocardial infarction (NSTEMI) differs from that of a patient with a STEMI, in that a STEMI is more frequently treated with which of the following? a) Thrombolytics b) IV nitroglycerin c) IV heparin d) Percutaneous coronary intervention (PCI)

d) Percutaneous coronary intervention (PCI) Explanation: The patient with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs? a) Pulmonary hypertension b) Heart palpitations c) Mitral valve stenosis d) Pulmonary congestion

d) Pulmonary congestion Explanation: Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Heart palpitations are caused by tachydysrhythmias. Crackles heard in the bases of the lungs are not signs of pulmonary hypertension and mitral valve stenosis

A 35-year-old female patient has been diagnosed with hypertension. The patient is a stock broker, smokes daily, and is also a diabetic. During a follow-up appointment, the patient states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her blood pressure (BP). As the nurse, which of the following aspects of patient teaching would you recommend? a) Discussing methods for stress reduction b) Administering glycemic control c) Advising a smoking cessation d) Purchasing a self-monitoring BP cuff

d) Purchasing a self-monitoring BP cuff Explanation: Because this patient finds it time consuming to visit the doctor just for a blood pressure reading, as the nurse, you can suggest the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff. Discussing methods for stress reduction, advising a smoking cessation, and administering glycemic control would constitute patient education in managing hypertension.

A 28-year-old female patient presents to the emergency department (ED) stating severe restlessness and anxiety. Upon assessment, the patient's heart rate is 118 bpm and regular, the patient's pupils are dilated, and the patient appears excitable. Which action should the nurse take next? a) Prepare to administer a calcium channel blocker. b) Instruct the patient to hold her breath and bear down. c) Place the patient on supplemental oxygen. d) Question the patient about alcohol and illicit drug use.

d) Question the patient about alcohol and illicit drug use. Explanation: The patient is experiencing sinus tachycardia. Since the patient's findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the patient about alcohol and illicit drug use. This information will direct the patient's plan of care. Causes of tachycardia include medications that stimulate the sympathetic response, stimulants, and illicit drugs. The treatment goals for sinus tachycardia is usually determined by the severity of symptoms and directed at identifying and abolishing its cause. The other interventions may be implemented, but determining the cause of the tachycardia is essential.

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? a) High blood pressure b) Increased urinary output c) Hyperactive bowel sounds d) Restlessness and confusion

d) Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

Which of the following is the term for the normal pacemaker of the heart? a) Purkinje fibers b) Atrioventricular (AV) node c) Bundle of His d) Sinoatrial (SA) node

d) Sinoatrial (SA) node Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.

What is the primary reason of adding Captopril to Mrs. Melnik's medication regimen? a) To reverse left ventricular hypertrophy b) To work as another diuretic c) To help control her blood pressure d) To prevent further left ventricular hypertrophy

d) To prevent further left ventricular hypertrophy Explanation: Captopril is an ACE inhibitor (not a diuretic). This class of drug has been demonstrated to prevent further LVH and is considered a standard of care for chronic HF. Beta-blockers have been demonstrated to reverse LVH and are also considered a standard of care for chronic HF. You recall that Mrs. Melnik was started on atenolol, a beta-blocker, at the start of the case. While captopril does reduce BP, its primary use for Mrs. Melnik is LVH protection.

The purpose of repeating the cardiac enzymes reading is to verify the original admission result. Is this statement true or false?

false Explanation: Cardiac enzymes begin to rise a few hours after myocardial injury. If a patient presents to the emergency department early in the course of an MI, the initial results may be normal while subsequent results are elevated, indicating myocardial injury.

Fatigue is a late manifestation of HF and is caused by increased cardiac output and decreased oxygenation of the tissues. False True

false Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

Frequent urination at night (nocturia) indicates a urinary tract infection.

Altered level of consciousness may indicate

hypoxia and intracranial bleeding and the infusion should be discontinued immediately.

Application of a vascular closure device (Angioseal, VasoSeal), direct manual pressure to the sheath introduction site, and application of a mechanical compression device (C-shaped clamp) are all appropriate methods used to

induce hemostasis following peripheral sheath removal.

The time frame of 9 days refers to the time for onset of vasculitis after administration of

streptokinase for thrombolysis in an acute MI patient.

The first signs of an acute MI are usually seen in

the T wave and ST segment. The T wave becomes inverted; the ST segment elevates (usually flat).

The client is instructed to take Nitroglycerin

three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted.

DOE and orthopnea are caused by increased pulmonary pressure due to interstitial and alveolar edema. False True

true Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

The development of dependant (ankle) edema is a sign of exacerbated HF. True False

Protamine sulfate is known as the antagonist for

unfractionated heparin (it neutralizes heparin).

60 minutes Explanation: The 60-minute interval is known as "door-to-balloon time" for performance of PTCA on a diagnosed MI patient. The 30-minute interval is known as "door-to-needle time" for administration of thrombolytics post MI. The time frame of 9 days refers to the time for onset of vasculitis after administration of streptokinase for thrombolysis in an acute MI patient. The 6 to 12 month time frame refers to the time period during which streptokinase will not be used again in the same patient for acute MI.

When assessing a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next? a. Auscultate for any cardiac murmurs. b. Find the point of maximal impulse. c. Compare the apical and radial pulse rates. d. Palpate the quality of the peripheral pulses.

ANS: A Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is heard, and where on the thorax the murmur is heard best. The other information also is important in the cardiac assessment but will not provide information that is relevant to the thrill. DIF: Cognitive Level: Application REF: 726

Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST segment elevation on the electrocardiogram (ECG) d. An increase in cardiac enzyme levels since admission

ANS: A Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Application REF: 782-783

A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Skin flushing after taking the medications c. Dizziness when changing positions quickly d. Nausea when taking the drugs before eating

ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow up with the patient, they do not indicate that a change in medication is needed. DIF: Cognitive Level: Application REF: 768-770

After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "It is important not to suddenly stop taking the atenolol." b. "Atenolol will increase the strength of my heart muscle." c. "I can expect to feel short of breath when taking atenolol." d. "Atenolol will improve the blood flow to my coronary arteries."

ANS: A Patients who have been taking -blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking -blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Application REF: 775 | 776

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left 5th intercostal space and midclavicular line. How will the nurse record this information? a. "Systolic murmur heard at mitral area." b. "Diastolic murmur heard at aortic area." c. "Systolic murmur heard at Erb's point." d. "Diastolic murmur heard at tricuspid area."

ANS: A The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left 5th intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle. DIF: Cognitive Level: Application REF: 725 | 726

Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Social isolation related to lack of support system

ANS: A The patient data indicates that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation. DIF: Cognitive Level: Application REF: 788-789

When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, a. "I will have incisions in my leg where they will remove the vein." b. "They will circulate my blood with a machine during the surgery." c. "I will need to take an aspirin a day after the surgery to keep the graft open." d. "They will use an artery near my heart to bypass the area that is obstructed."

ANS: A When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 783-784

When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: B Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible. DIF: Cognitive Level: Application REF: 779-780 | 787-788

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. LDL cholesterol. b. troponins T and I. c. C-reactive protein. d. creatine kinase-MB (CK-MB).

ANS: B Cardiac troponins start to elevate hours (average 4 to 6 hours) after myocardial injury and are specific to myocardium. Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction. DIF: Cognitive Level: Application REF: 726-727

Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has persisted longer than 30 minutes. c. The pain worsens when the patient raises the arms. d. The pain is relieved after the patient takes nitroglycerin.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin. DIF: Cognitive Level: Application REF: 779

For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about a. typical emotional responses to AMI. b. when patient cardiac rehabilitation will begin. c. discharge drugs such as aspirin and -blockers. d. the pathophysiology of coronary artery disease.

ANS: B Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as coronary artery disease (CAD) pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI). DIF: Cognitive Level: Application REF: 788-789

A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Do you take aspirin on a daily basis?" b. "What time did your chest pain begin?" c. "Is there any family history of heart disease?" d. "Can you describe the quality of your chest pain?"

ANS: B Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information also will be needed, but it will not be a factor in the decision about fibrinolytic therapy. DIF: Cognitive Level: Application REF: 782-783

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient a. that sudden cardiac death events rarely reoccur. b. about the purpose of outpatient Holter monitoring. c. how to self-administer low-molecular-weight heparin. d. to limit activities after discharge to prevent future events.

ANS: B Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Application REF: 793-794

Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will a. reduce the "fight or flight" response. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. help prevent clotting in the coronary arteries.

ANS: B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help prevent coronary artery thrombosis, and -blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. DIF: Cognitive Level: Application REF: 776

A patient who has had an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will discuss sexual intercourse when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The other responses do not directly address the patient's question, or may not be accurate for this patient. DIF: Cognitive Level: Application REF: 792

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. electrocardiographic (ECG) monitoring will be required for 24 hours after the test. b. it will be important to lie completely still during the procedure. c. a warm feeling may be noted when the contrast dye is injected. d. monitored anesthesia care will be provided during the procedure.

ANS: C A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. ECG monitoring is used during the procedure to detect dysrhythmias, but there is not a risk for dysrhythmias after the procedure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths. DIF: Cognitive Level: Application REF: 732 | 735-736

Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% or nonfat milk." b. "I like fresh salmon and I will plan to eat it more often." c. "I will miss being able to eat peanut butter sandwiches." d. "I can have a cup of coffee with breakfast if I want one."

ANS: C Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Application REF: 768

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish and iodine. b. The patient has a history of coronary artery disease. c. The patient has a permanent ventricular pacemaker in place. d. The patient took all the prescribed cardiac medications today.

ANS: C MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information also will be reported to the health care provider but does not impact on whether or not the patient can have an MRI. DIF: Cognitive Level: Application REF: 731-732 | 734-735

During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Application REF: 783-784

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first? a. Administer O2 per mask. b. Start a large-gauge IV line. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.

ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure. DIF: Cognitive Level: Application REF: 730

Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Palpate the radial pulses bilaterally. b. Assess the feet for peripheral edema. c. Auscultate for a pericardial friction rub. d. Check the cardiac monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Application REF: 780

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient complaint of feeling tired. b. Pulse change from 80 to 96 beats/minute. c. BP increase from 134/68 to 150/80 mm Hg. d. Electrocardiographic (ECG) changes indicating coronary ischemia.

ANS: D ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate (HR) are normal responses to aerobic exercise. Tiredness also is normal as the intensity of exercise increases during the stress testing. DIF: Cognitive Level: Application REF: 730

A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Platelet aggregation is enhanced by IV heparin infusion. b. Heparin will dissolve the clot that is blocking blood flow to the heart. c. Coronary artery plaque size and adherence are decreased with heparin. d. Heparin will prevent the development of new clots in the coronary arteries.

ANS: D Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. DIF: Cognitive Level: Comprehension REF: 775

Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? a. Evaluating the patient's response to ambulation in the hallway b. Completing the documentation for a home health nurse referral c. Educating the patient about the pathophysiology of heart disease d. Reinforcing teaching about the purpose of prescribed medications

ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice. DIF: Cognitive Level: Application REF: 789-793

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if a. the patient is restless and agitated. b. the blood pressure is 190/110 mm Hg. c. the patient complains about feeling anxious. d. the cardiac monitor shows a heart rate of 45.

ANS: D Patients taking -blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. DIF: Cognitive Level: Application REF: 776

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when giving the medication? a. Administer the medication at the patient's bedtime. b. Have the patient take this medication with an aspirin. c. Encourage the patient to take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.

ANS: D The bile acid sequestrants interfere with the absorption of other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals. DIF: Cognitive Level: Application REF: 770-771

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? a. Pedal pulses 1+ b. Heart rate 100 beats/min c. Blood pressure 104/56 mm Hg d. Chest pain level 8 on a 10-point scale

ANS: D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. DIF: Cognitive Level: Application REF: 781-782

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease? a) Assess the physical history of the patient b) Assess the blood pressure and administer aspirin c) Not important to assess the patient or to notify the physician d) Assess chest pain and administer prescribed drugs and oxygen

Assess chest pain and administer prescribed drugs and oxygen Correct Explanation: The nurse assesses the patient for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing the blood pressure or the physical history does not clearly indicate that the patient has CAD. The nurse does not administer aspirin without the physician's prescription.

A middle-aged male presents to the ED complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible MI? a) Cool, clammy, diaphoretic, and pale appearance b) Chest discomfort not relieved by rest or nitroglycerin c) Intermittent nausea and emesis for 3 days d) Anxiousness, restlessness, and lightheadedness

Chest discomfort not relieved by rest or nitroglycerin Correct Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with ACS (acute coronary syndrome) or MI, may also occur with angina and, alone, are not indicative of an MI.

Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin? a) Amlodipine (Norvasc) b) Clopidogrel (Plavix) c) Felodipine (Plendil) d) Diltiazem (Cardizem)

Clopidogrel (Plavix) Correct Explanation: Plavix or Ticlid is given to patients who are allergic to aspirin or given in addition to aspirin to patients at high risk for MI. Norvasc, Cardizem, and Plendil are calcium channel blockers.

A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client? a) Venous occlusive disease b) Cardiogenic shock c) Coronary artery disease d) Raynaud's disease

Coronary artery disease Correct Explanation: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud's disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.

A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following? a) Increases cardiac output b) Decreases resting heart rate c) Decreases cholesterol level d) Decreases platelet aggregation

Decreases resting heart rate Correct Explanation: The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. Generally the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

You are caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client? a) Examine for pain around the shoulder and neck region. b) Examine the extremities for skin lesions. c) Examine the legs for color, capillary refill time, and tissue integrity. d) Examine the client's mental and emotional status.

Examine the legs for color, capillary refill time, and tissue integrity. Correct Explanation: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.

A patient presents to the emergency room with characteristics of atherosclerosis. What characteristics would the patient display? a) Fatty deposits in the lumen of arteries b) Blood clots in the arteries c) Emboli in the veins d) Cholesterol plugs in the lumen of veins

Fatty deposits in the lumen of arteries Correct Explanation: Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, options B, C, and D are incorrect.

The lab values of a patient diagnosed with coronary artery disease (CAD) have just come back from the lab. His low-density lipoprotein (LDL) level is 112 mg/dL. This lab value is indicative of which of the following? a) High LDL level b) Normal LDL level c) Low LDL level d) Extremely high LDL level

High LDL level Correct Explanation: If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be high. The goal is to decrease the LDL level below 100 mg/dL.

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document? a) Urinary incontinence b) Hypertension c) Hypotension d) Hyperactive bowel sounds

Hypotension Correct Explanation: The patient is observed for any adverse effects of opioids, which may include respiratory depression, hypotension, ileus, or urinary retention. If serious side effects occur, an opioid antagonist, such as Narcan, may be used.

Which of the following would be inconsistent as criterion of extubation in the patient who has undergone a coronary artery bypass graft (CABG)? a) Inability to speak. b) Adequate cough and gag reflex. c) Adequate vital capacity. d) Acceptable arterial blood gas (ABG) values.

Inability to speak. Correct Explanation: Before being extubated, the patient should have cough and gag reflexes and stable vital signs; be able to life the head off the bed or give firm hand grasps; have adequate vital capacity, negative inspiratory force, and minute volume appropriate for body size; and have acceptable ABG levels while breathing without the assistance of the ventilator. Inability to talk is expected when intubated with an endotracheal tube.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (less than 25 mL per hour) with high specific gravity (greater than 1.025), the nurse suspects which of the following conditions? a) Overhydration b) Anuria c) Inadequate fluid volume d) Normal glomerular filtration

Inadequate fluid volume Correct Explanation: Urine output of less than 25 mL per hour may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 25 mLor greater per hour and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric patient does not produce urine.

Which of the following is the most important postoperative assessment parameter for patients undergoing cardiac surgery? a) Blood glucose level b) Activity intolerance c) Inadequate tissue perfusion d) Mental alertness

Inadequate tissue perfusion Correct Explanation: The nurse must assess the patient for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood sugar and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for patients undergoing cardiac surgery.

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? a) Cleanse the site with disinfectants and dress the wound appropriately b) Normal activities of daily living can be resumed the first day post op c) Monitor the site for bleeding or hematoma. d) Refrain from sexual activity for one month

Monitor the site for bleeding or hematoma. Correct Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or development of a hard mass indicative of hematoma. A nurse does not advise the patient to clean the site with disinfectants or refrain from sexual activity for one month.

The nurse recognizes that the treatment for a non-ST elevation myocardial infarction (NSTEMI) differs from that of a patient with a STEMI, in that a STEMI is more frequently treated with which of the following? a) IV nitroglycerin b) Percutaneous coronary intervention (PCI) c) Thrombolytics d) IV heparin

Percutaneous coronary intervention (PCI) Correct Explanation: The patient with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome? a) Decreased erythrocyte sedimentation rate (ESR) b) Decreased white blood cell (WBC) count c) Hypothermia d) Pericardial friction rub

Pericardial friction rub Correct Explanation: The syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR.

The nurse is observing a patient during an exercise stress test (bicycle). Which of the following findings indicates a positive test and the need for further diagnostic testing? a) Heart rate changes; 78 bpm to 112 bpm b) ST-segment changes on the ECG c) BP changes; 148/80 mm Hg to 166/90 mm Hg d) Dizziness and leg cramping

b) ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the patient experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the patient develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant the testing to be stopped.

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