Critical Care Practice

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The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following? ■ 1. Obtaining an infusion pump for the medication. ■ 2. Monitoring blood pressure every 4 hours. ■ 3. Monitoring urine output hourly. ■ 4. Obtaining serum potassium levels daily.

ANS 1. I.V. nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to: ■ 1. Help keep him well hydrated. ■ 2. Dissolve clots that he may have. ■ 3. Prevent kidney failure. ■ 4. Treat potential cardiac arrhythmias.

ANS 2 Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet? ■ 1. Hamburger, salad, and milkshake. ■ 2. Baked liver, green beans, and coffee. ■ 3. Spaghetti with tomato sauce, salad, and coffee. ■ 4. Fried chicken, green beans, and skim milk.

ANS 3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by: ■ 1. Left ventricular overload. ■ 2. Impending circulatory collapse. ■ 3. Extracellular electrolyte imbalances. ■ 4. Insuffi cient oxygen reaching the heart muscle.

ANS 4. An MI interferes with or blocks blood circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina. The pain is not due to ventricular overload, circulatory collapse, or electrolyte imbalances.

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: ■ 1. Control chest pain. ■ 2. Reduce coronary artery vasospasm. ■ 3. Control the arrhythmias associated with MI. ■ 4. Revascularize the blocked coronary artery.

ANS 4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? ■ 1. Take one tablet every 2 to 5 minutes until the pain stops. ■ 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. ■ 3. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets. ■ 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.

3. The correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes.

After the administration of t-PA, the assessment priority is to: ■ 1. Observe the client for chest pain. ■ 2. Monitor for fever. ■ 3. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. ■ 4. Monitor breath sounds.

ANS 1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first: ■ 1. Administer the morphine. ■ 2. Obtain a 12-lead ECG. ■ 3. Obtain the blood work. ■ 4. Order the chest radiograph.

ANS 1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

A client is admitted with a myocardial infarction and new onset atrial fi brillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: ■ 1. Heart rate irregular with S3. ■ 2. Heart rate irregular with S4. ■ 3. Heart rate irregular with aortic regurgitation. ■ 4. Heart rate irregular with mitral stenosis.

ANS 1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? ■ 1. Cardiac arrhythmias. ■ 2. Hypertension. ■ 3. Seizure. ■ 4. Hypothermia.

ANS 1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.

A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: ■ 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. ■ 2. Administer oxygen via nasal cannula. ■ 3. Offer pain medication for the chest heaviness. ■ 4. Inform the physician of the chest heaviness.

ANS 1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: ■ 1. Left ventricular atrophy. ■ 2. Irregular heartbeats. ■ 3. Peripheral vascular occlusion. ■ 4. Pacemaker placement.

ANS 1. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormalchanges in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifi es a new systolic murmur at the apex. The nurse should first: ■ 1. Assess for changes in vital signs. ■ 2. Draw an arterial blood gas. ■ 3. Evaluate heart sounds with the client leaning forward. ■ 4. Obtain a 12 Lead electrocardiogram.

ANS 1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? ■ 1. A change in the pattern of her pain. ■ 2. Pain during sexual activity. ■ 3. Pain during an argument with her husband. ■ 4. Pain during or after an activity such as lawn-mowing.

ANS 1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn-mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? ■ 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. ■ 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. ■ 3. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. ■ 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

ANS 2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable.

Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction? ■ 1. Liquids as desired. ■ 2. Small, easily digested meals. ■ 3. Three regular meals per day. ■ 4. Nothing by mouth.

ANS 2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following? ■ 1. Age greater than 60 years. ■ 2. History of cerebral hemorrhage. ■ 3. History of heart failure. ■ 4. Cigarette smoking.

ANS 2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to: ■ 1. Call for the physician. ■ 2. Start an I.V. line. ■ 3. Obtain a portable chest radiograph. ■ 4. Draw blood for laboratory studies.

ANS 2. Advanced cardiac life support recommends that at least one or two I.V. lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the I.V. line.

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: ■ 1. Open and dilate blocked coronary arteries. ■ 2. Assess the extent of arterial blockage. ■ 3. Bypass obstructed vessels. ■ 4. Assess the functional adequacy of the valves and heart muscle.

ANS 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.

Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide? ■ 1. Increased blood pressure. ■ 2. Increased urine output. ■ 3. Decreased pain. ■ 4. Decreased premature ventricular contractions.

ANS 2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.

Which of the following is not a risk factor for the development of atherosclerosis? ■ 1. Family history of early heart attack. ■ 2. Late onset of puberty. ■ 3. Total blood cholesterol level greater than 220 mg/dL. ■ 4. Elevated fasting blood glucose concentration.

ANS 2. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity.

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders should the nurse question? ■ 1. Call for urine output < 30 mL/hour for 2 consecutive hours. ■ 2. Metoprolol (Lopressor) 5 mg I.V. push. ■ 3. Prepare for a pulmonary artery catheter insertion. ■ 4. Titrate Dobutamine (Dobutrex) to keep systolic BP > 100.

ANS 2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.

A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? ■ 1. Serum potassium is 3.5 mEq/L. ■ 2. Blood pressure is 88/46. ■ 3. ST elevation is present on the electrocardiogram. ■ 4. Heart rate is 61.

ANS 2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be to: ■ 1. Increase the I.V. infusion rate. ■ 2. Notify the physician promptly. ■ 3. Increase the oxygen concentration. ■ 4. Administer a prescribed analgesic.

ANS 2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the I.V. infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: ■ 1. Antispasmodic effects on the pericardium. ■ 2. Causing an increased myocardial oxygen demand. ■ 3. Vasodilation of peripheral vasculature. ■ 4. Improved conductivity in the myocardium.

ANS 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

A client with angina has been taking nifedipine. The nurse should teach the client to: ■ 1. Monitor blood pressure monthly. ■ 2. Perform daily weights. ■ 3. Inspect gums daily. ■ 4. Limit intake of green leafy vegetables.

ANS 3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.

If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: ■ 1. Explaining how the old behavior leads to poor health. ■ 2. Withholding praise until the new behavior is well established. ■ 3. Rewarding the client whenever the acceptable behavior is performed. ■ 4. Instilling mild fear into the client to extinguish the behavior.

ANS 3. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? ■ 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a lowfat diet." ■ 2. "The triglycerides are elevated and will not return to normal without these medications." ■ 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." ■ 4. "The medications are not indicated since your lab values are all normal."

ANS 3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

During the previous few months, a 56-yearold woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem? ■ 1. Visit her friend early in the day. ■ 2. Rest for at least an hour before climbing the stairs. ■ 3. Take a nitroglycerin tablet before climbing the stairs. ■ 4. Lie down once she reaches the friend's apartment.

ANS 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do? ■ 1. Put the tablet under the tongue until it is absorbed. ■ 2. Swallow the tablet with 120 mL of water. ■ 3. Chew the tablet until it is dissolved. ■ 4. Place the tablet between his cheek and gums.

ANS 3. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The nitroglycerin tablet will be absorbed fastest if the client chews the tablet.

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help: ■ 1. Prepare the client for ambulation. ■ 2. Promote urinary and intestinal elimination. ■ 3. Prevent thrombophlebitis and blood clot formation. ■ 4. Decrease the likelihood of pressure ulcer formation.

ANS 3. This type of exercise is a preventive strategy taught to all clients who are hospitalized and on bed rest. This activity is taught to the client to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. It is venous stasis that increases one's risk for thrombophlebitis and blood clot formation. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.

The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include: ■ 1. Minimizing dyspnea. ■ 2. Maintaining adequate blood pressure control. ■ 3. Decreasing myocardial contractility. ■ 4. Preventing fl uid volume defi cit.

ANS 4. Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.

Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: ■ 1. Has severe chest pain. ■ 2. Can identify risk factors for MI. ■ 3. Agrees to participate in a cardiac rehabilitation walking program. ■ 4. Can perform personal self-care activities without pain.

ANS 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program

Crackles heard on lung auscultation indicate which of the following? ■ 1. Cyanosis. ■ 2. Bronchospasm. ■ 3. Airway narrowing. ■ 4. Fluid-filled alveoli.

ANS 4. Crackles are auscultated over fl uid-fi lled alveoli. Crackles heard on lung auscultation do nothave to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? ■ 1. Cancer. ■ 2. Hypertension. ■ 3. Liver disease. ■ 4. Myocardial damage.

ANS 4. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction. Myoglobin does not help diagnose cancer, hypertension, or liver disease.

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time? ■ 1. Monitor daily weights and urine output. ■ 2. Permit unrestricted visitation by family and friends. ■ 3. Provide client education on medications and diet. ■ 4. Reduce pain and myocardial oxygen demand.

ANS 4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: ■ 1. Administer Atropine 0.5 mg I.V. push. ■ 2. Auscultate for abnormal heart sounds. ■ 3. Prepare for transcutaneous pacing. ■ 4. Take the client's blood pressure.

ANS 4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? ■ 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. ■ 2. A 43-year-old male with a family history of CAD and cholesterol level of 158. ■ 3. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor). ■ 4. A 65-year-old female who is obese with an LDL of 188.

ANS 4. The woman who is 65 years old, overweight and has an elevated LDL is at greatest risk. Total cholesterol > 200, LDL > 100, HDL < 40 in men, HDL < 50 in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity, and high LDL cholesterol places this client at greatest risk.

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: ■ 1. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. ■ 2. Nitroglycerin should be avoided if the client is experiencing this serious side effect. ■ 3. Taking the nitroglycerin with a few glasses of water will reduce the problem. ■ 4. The client should lie in a supine position to alleviate the headache.

1. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying fl at will increase blood fl ow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? ________________________ mL/hour.

24 mL/hour

A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. ■ 1. Reduces myocardial oxygen consumption. ■ 2. Promotes reduction in respiratory rate. ■ 3. Prevents ventricular remodeling. ■ 4. Reduces blood pressure and heart rate. ■ 5. Reduces anxiety and fear.

ANS 1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe? ■ 1. Oliguria. ■ 2. Bradycardia. ■ 3. Elevated blood pressure. ■ 4. Fever.

ANS 1. Oliguria occurs during cardiogenic shock because there is reduced blood fl ow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock