LaCharity Chapter 7: Cardiovascular Problems

16. The nurse is working with an experienced assistive personnel (AP) and an LPN/LVN on the telemetry unit. A patient who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN? 1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during patient activities 2. Taking pulse, blood pressure, and oxygen saturation before and after patient ambulation 3. Teaching the patient energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the patient and family

1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during patient activities Ans: 1 Administration of nitroglycerin and appropriate patient monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Taking of blood pressure, pulse, and oxygen saturation should be delegated to the AP. Patient teaching requires RN-level education and scope of practice.

41. During the initial postoperative assessment of a patient who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the patient's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

1. Arterial line indicates a blood pressure of 190/112 mm Hg. Ans: 1 Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the patient's hemodynamic stability.

8. The health care provider prescribes these actions for a patient who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply. 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the patient about pertinent medical history 6. Having the patient chew and swallow aspirin 162 mg

1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the patient chew and swallow aspirin 162 mg Ans: 1, 4, 6 Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable patients, these are highalert medications that should be given by the RN to this unstable patient. Obtaining a pertinent medical history requires RN-level education and scope of practice.

1. An RN is admitting a patient to the cardiac unit who has stable angina and a history of type 2 diabetes mellitus. The patient is scheduled for a cardiac catheterization the next day. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glucophage 2. Glimepiride 3. Pravastatin 4. Vitamin C

1. Glucophage Ans: 1 Glucophage should be withheld 24 hours before and 48 hours after cardiac catheterization. Contrast medium is used during a cardiac catherization and can affect kidney function, leaving the patient at an increased risk for lactic acidosis. The rest of the medications do not need to be withheld for longer than the recommended time the patient would need to be NPO.

3. Which topics will the nurse plan to include in discharge teaching for a patient who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

1. How to monitor and record daily weight 3. Symptoms of worsening heart failure 5. How to read food labels for sodium content 6. Date and time for follow-up appointments Ans: 1, 3, 5, 6 To avoid rehospitalization, topics that should be included when discharging a patient with heart failure include how to maintain a low-sodium diet, the purpose and common side effects of medications such as angiotensin converting enzyme inhibitors and beta-blockers, what to do if symptoms of worsening heart failure occur, and the scheduling of follow-up appointments. The nurse will teach the patient that a moderate increase in heart rate and respiratory effort is normal with exercise. Antibiotics are not included in the treatment regimen for heart failure, which is not an infectious process.

26. The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced assistive personnel (AP)? 1. Measuring ankle and brachial pressures in a patient for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a patient who is undergoing exercise testing 3. Obtaining information about allergies from a patient who is scheduled for left leg contrast venography 4. Providing brief patient teaching for a patient who will undergo a right subclavian vein Doppler study

1. Measuring ankle and brachial pressures in a patient for whom the ankle-brachial index is to be calculated Ans: 1 Measurement of ankle and brachial blood pressures for calculation is within the AP's scope of practice. Calculating the ankle-brachial index and any referrals or discussion with the patient are the responsibility of the supervising RN. The other patients require more complex assessments or patient teaching, which should be done by an experienced RN.

2. The clinic nurse is evaluating a patient who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the patient is most important to report to the health care provider? 1. Patient is experiencing shortness of breath and fatigue. 2. Bruising is present at the right groin. 3. Home blood pressure today was 104/52 mm Hg. 4. Home radial pulse rate has been 55 to 60 beats/min.

1. Patient is experiencing shortness of breath and fatigue. Ans: 1 Shortness of breath and fatigue may indicate anemia from gastrointestinal bleeding, which is a possible adverse effect of both aspirin and clopidogrel. The patient will need to continue on the medications but may need treatment with proton pump inhibitors or histamine2 blockers to decrease risk for gastrointestinal bleeding. The other findings will also be reported to the health care provider but will not require a change in the therapeutic plan for the patient.

23. At 10:00 AM, a hospitalized patient receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first? 1. Put the patient on NPO status. 2. Teach the patient about the procedure. 3. Insert an IV catheter in the patient's forearm. 4. Attach the patient to a cardiac monitor.

1. Put the patient on NPO status. Ans: 1 Because transesophageal echocardiography is performed after the throat is numbed using a topical anesthetic and with the use of IV sedation, it is important that the patient be placed on NPO status for several hours before the test. The other actions will also need to be accomplished before the echocardiogram but do not need to be implemented immediately.

5. Which finding in a patient with aortic stenosis will be most important for the nurse to report to the health care provider? 1. Temperature of 102.1°F (38.9°C) 2. Loud systolic murmur over sternum 3. Blood pressure of 110/88 mm Hg 4. Weak radial and pedal pulses to palpation

1. Temperature of 102.1°F (38.9°C) Ans: 1 Because endocarditis is a concern with valvular disease, an elevated temperature indicates a need for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systolic murmur, decreased pulse pressure, and weak pulses would be expected in a patient with aortic stenosis and would not indicate an immediate need for further evaluation or treatment.

20. The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a patient who has had a myocardial infarction and the patient's spouse. The patient says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

2. "Can you tell me why you don't feel that you need to make any changes?" Ans: 2 For behavior to change, the patient must be aware of the need to make changes. This response acknowledges the patient's statement and asks for further clarification. This will give the nurse more information about the patient's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the patient is ready or not and are not likely to lead to changes in lifestyle

27. While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which patient will be best to assign to the new graduate? 1. A 19-year-old patient with rheumatic fever who needs discharge teaching before going home with a roommate today 2. A 33-year-old patient admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV 3. A 50-year-old patient with newly diagnosed stable angina who has many questions about medications and nursing care 4. A 75-year-old patient who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

2. A 33-year-old patient admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV Ans: 2 The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and patient care. The other patients require more complex assessment or patient teaching by an RN with experience in caring for patients with these diagnoses

31. The nurse has just received a change-of-shift report about these patients on the coronary step-down unit. Which one will the nurse assess first? 1. A 26-year-old patient with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. A 45-year-old patient with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. A 56-year-old patient who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. A 77-year-old patient who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

2. A 45-year-old patient with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change Ans: 2 The patient's symptoms indicate acute hypoxia, so immediate further assessments (e.g., assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other patients should also be assessed soon because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic patient.

44. A patient seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

2. B-type natriuretic peptide Ans: 2 Research indicates that B-type natriuretic peptide levels increase in patients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the patient has heart failure.

35. The nurse is ambulating a cardiac surgery patient whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? 1. Call the patient's health care provider. 2. Have the patient sit down. 3. Check the patient's blood pressure. 4. Administer as needed oxygen by nasal cannula. _____, _____, _____, _____

2. Have the patient sit down. 4. Administer as needed oxygen by nasal cannula. 3. Check the patient's blood pressure. 1. Call the patient's health care provider. Ans: 2, 4, 3, 1 Because the increased heart rate may be associated with a decrease in blood pressure and with lightheadedness, the nurse's first action should be to decrease risk for a fall by having the patient sit down. Cardiac ischemia may be causing the patient's tachycardia, and administration of supplemental oxygen should be the next action. Assessment of blood pressure should be done next. Finally, the health care provider should be notified about the patient's response to activity because changes in therapy may be indicated. F

22. The health care provider telephones the nurse with new prescriptions for a patient with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider? 1. Clopidogrel 75 mg/day 2. Ibuprofen 200 mg every 4 hours as needed 3. Metoprolol succinate 50 mg/day 4. Nitroglycerin patch 0.4 mg/hr

2. Ibuprofen 200 mg every 4 hours as needed Ans: 2 Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for patients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the patient but should be verified because the prescriptions were received by telephone.

39. The clinic nurse obtains this information about a patient who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Patient reports eating a green salad for lunch every day.

2. International normalized ratio (INR) is 1.2. Ans: 2 An INR of 1.2 is not within the expected therapeutic range of 2 to 3 and indicates a need for an increase in the warfarin dose. The blood pressure is in the low to normal range. Although the patient will be encouraged to avoid injury, increased bruising is common when patients are taking anticoagulants and not a reason to discontinue the medication. Although foods that are high in vitamin K will have an impact on INR, this is not a concern when these foods are eaten consistently because the warfarin dose will be adjusted accordingly.

32. The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and assistive personnel (AP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

2. Listening to lung sounds and checking for edema each week Ans: 2 LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable patients. Weighing the residents should be delegated to an AP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice

12. Which patient is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Patient requiring discharge teaching about coronary artery stenting before going home today 2. Patient receiving IV furosemide to treat acute left ventricular failure 3. Patient who just transferred in from the radiology department after a coronary angioplasty 4. Patient just admitted with unstable angina who has orders for a heparin infusion and aspirin

2. Patient receiving IV furosemide to treat acute left ventricular failure Ans: 2 An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other patients need to be cared for by RNs who are more familiar with the care of patients who have acute coronary syndrome and with collaborative treatments such as coronary angioplasty and coronary artery stenting.

40. The nurse in the cardiovascular clinic receives telephone calls from four patients. Which patient should be scheduled to be seen most urgently? 1. Patient with peripheral arterial disease who complains of leg cramps when walking 2. Patient with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Patient with a new permanent pacemaker who has severe itchiness at the wound site 4. Patient with angina who took nitroglycerin twice in the last week while exercising

2. Patient with atrial fibrillation who reports episodes of lightheadedness and syncope Ans: 2 Lightheadedness and syncope may indicate that the patient's heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other patients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled.

14. The nurse is caring for a patient who has heart failure and a new prescription for sacubitril-valsartan. Which patient information is most important to discuss with the health care provider before administration of the medication? 1. The patient's oxygen saturation is 92%. 2. The patient receives lisinopril 10 mg/day. 3. The patient's blood pressure is 150/90 mm Hg. 4. The patient's potassium is 3.3 mEq/L (3.3 mmol/L).

2. The patient receives lisinopril 10 mg/day. Ans: 2 Because combination angiotensin receptor blocker-neprilysin blockers markedly increase the risk for angioedema in patients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril-valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension are increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril-valsartan

6. A patient who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

2. Troponin I level Ans: 2 Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarction (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglobin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myoglobin is nonspecific. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction

17. The emergency department nurse is caring for a patient who was just admitted with left anterior chest pain, suggesting possible acute myocardial infarction (MI). Which action will the nurse take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

3. Administer sublingual nitroglycerin. Ans: 3 The priority for a patient with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority

15. A patient whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the patient about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the patient about lifestyle changes such as a low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the patient to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the patient with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

3. Ask the patient to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. Ans: 3 The American Heart Association recommends home blood pressure monitoring for patients with hypertension or hypertension risk factors because home blood pressure monitoring provides more accurate data about usual blood pressure than periodic monitoring. The other actions may be necessary, but further assessment of the patient's usual blood pressure is needed before decisions about therapy can be made.

42. The nurse is developing a standardized care plan for the postoperative care of patients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the patient out of bed on the first postoperative day

3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes Ans: 3 Development of plans for patient care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.

43. The nurse is preparing to administer the following medications to a patient with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine 20 mg IV 2. Furosemide 40 mg IV 3. Digoxin 0.25 mg PO 4. Warfarin 2.5 mg PO

3. Digoxin 0.25 mg PO Ans: 3 Development of plans for patient care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.

34. During a home visit to an 88-year-old patient who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse 68 beats/min and irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

3. Vision that is becoming "fuzzy" Ans: 3 The patient's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure

18. An 80-year-old patient on the coronary step-down unit tells the nurse, "I do not need to take that docusate. I never get constipated!" Which action by the nurse is most appropriate? 1. Document the medication on the patient's chart as "refused." 2. Mix the medication with food and administer it to the patient. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

3. Explain that his decreased activity level may cause constipation. Ans: 3 The best option in this situation is to educate the patient about the purpose of the docusate (to counteract the negative effects of immobility and opiate use on peristalsis). Charting the medication as "refused" or telling the patient that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as patient education. It is unethical to administer a medication to a patient who is unwilling to take it unless someone else has health care power of attorney and has authorized use of the medication

36. A patient who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next? 1. Lower the patient's left foot below heart level. 2. Administer oxygen at 4 L/min to the patient. 3. Notify the health care provider about the change in status. 4. Reassure the patient that embolization is common in endocarditis.

3. Notify the health care provider about the change in status. Ans: 3 The patient's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the health care provider should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the patient that embolization is a common complication of endocarditis will not reassure a patient who is experiencing acute pain.

10. The nurse makes a home visit to evaluate a hypertensive patient who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Patient reports frequent urination. 2. Patient's blood pressure is 138/86 mm Hg. 3. Patient complains about a frequent dry cough. 4. Patient says, "I get dizzy sometimes if I stand up fast."

3. Patient complains about a frequent dry cough. Ans: 3 A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more patient teaching and ongoing monitoring but would not require a change in therapy

24. A patient with stable angina has a prescription for ranolazine 500 mg twice a day. Which patient finding is most important for the nurse to discuss with the health care provider (HCP)? 1. Heart rate is 52 beats/min. 2. Patient is also taking carvedilol for angina. 3. Patient reports having chronic constipation. 4. Blood pressure is 106/56 mm Hg.

3. Patient reports having chronic constipation. Ans: 3 Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the patient plan of care.

28. The nurse is monitoring the cardiac rhythms of patients in the coronary care unit. Which patient will need immediate intervention? 1. Patient admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Patient with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Patient who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Patient who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

3. Patient who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Ans: 3 Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other patients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of myocardial infarction.

21. The nurse is caring for a hospitalized patient with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood glucose level 3. Potassium level 4. Alkaline phosphatase level

3. Potassium level Ans: 3 Hyperkalemia is a common adverse effect of both angiotensin-converting enzyme inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening.

30. Two weeks ago, a patient with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the patient in the cardiology clinic is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

3. Sinus bradycardia at a rate of 48 beats/min Ans: 3 Research indicates that mortality is decreased when patients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for patients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. Nevertheless, a heart rate of 48 beats/min indicates a need to decrease the carvedilol dose.

33. The nurse is participating as a team member in the resuscitation of a patient who has experienced a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next? 1. Prepare to defibrillate the patient. 2. Offer to take over chest compressions. 3. State: "Epinephrine 1 mg IV has been given." 4. Continue to monitor the patient's responsiveness.

3. State: "Epinephrine 1 mg IV has been given." Ans: 3 The American Heart Association recommends "closed loop" communication between team members who are involved in resuscitation of a patient. The other actions may also be needed, but the initial action after administering a medication is to ensure that the team leader knows that the prescribed medication has been administered

47. The RN in an emergency room has triaged four patients who arrived simultaneously. List the order in which the patients should be seen. 1. A 14-year-old healthy male presenting with a swollen, discolored, and painful ankle (7 on a scale of 1-10). He reports he fell off his all-terrain vehicle. Vital signs are temperature (T) 37°C (98.6°F), pulse (P) 90 regular, respiratory rate (R) 20, oxygen saturation (O2 Sat) 98% room air, and blood pressure (BP) 130/90. 2. A 24-year-old female with a history of mitral valve prolapse presenting with vomiting and diarrhea. She reports the symptoms started after breakfast 2 hours ago and complains of being somewhat lightheaded. Vital signs are T 39°C (102.2°F), P 110 regular, R 18, O2 Sat 93% room air, and BP 94/62. 3. An 80-year-old female with a history of congestive heart failure presenting with constipation. She reports that she hasn't had a bowel movement in 2 weeks and is uncomfortable. Vital signs are T 36.4°C (97.5°F), P 77 irregular, R 16, O 4. A 54-year-old obese male with a history of diabetes presenting with dyspnea, nausea, and indigestion. He reports that he has had the flu all week. Vital signs are T 38°C (100.4°F), P 84 irregular, R 22, O2 Sat 95% on room air, and BP 140/92.

4. A 54-year-old obese male with a history of diabetes presenting with dyspnea, nausea, and indigestion. He reports that he has had the flu all week. Vital signs are T 38°C (100.4°F), P 84 irregular, R 22, O2 Sat 95% on room air, and BP 140/92. 2. A 24-year-old female with a history of mitral valve prolapse presenting with vomiting and diarrhea. She reports the symptoms started after breakfast 2 hours ago and complains of being somewhat lightheaded. Vital signs are T 39°C (102.2°F), P 110 regular, R 18, O2 Sat 93% room air, and BP 94/62. 1. A 14-year-old healthy male presenting with a swollen, discolored, and painful ankle (7 on a scale of 1-10). He reports he fell off his all-terrain vehicle. Vital signs are temperature (T) 37°C (98.6°F), pulse (P) 90 regular, respiratory rate (R) 20, oxygen saturation (O2 Sat) 98% room air, and blood pressure (BP) 130/90. 3. An 80-year-old female with a history of congestive heart failure presenting with constipation. She reports that she hasn't had a bowel movement in 2 weeks and is uncomfortable. Vital signs are T 36.4°C (97.5°F), P 77 irregular, R 16, O Ans: 4, 2, 1, 3 Patient #4 has symptoms of an ischemic pain pattern and has at least two risk factors for a myocardial infarction (diabetes and obesity). His temp of 38°C is an inflammatory reaction to myocardial damage that could have occurred earlier in the week (he complained of "flu" symptoms all week). Patient #2 should be seen next. Her symptoms started within hours of eating, which could indicate food poisoning. She is febrile, tachycardic, and her lightheadedness could be a result of dehydration. Patient #1 is stable, as is Patient #3; however, the 14-year-old is in pain and should have an x-ray as soon as possible to rule out a fracture.

25. The nurse assesses a patient who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 154/78 mm Hg. 2. Pedal pulses are palpable at + 1. 3. Left groin has a 3-cm bruised area. 4. Apical pulse is 122 beats/min and regular

4. Apical pulse is 122 beats/min and regular Ans: 4 The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern.

37. A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the assistive personnel (AP)? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the patient in cleaning around the Unna boot

4. Assisting the patient in cleaning around the Unna boot Ans: 4 Assisting with hygiene is included in the role and education of the AP. Assessments and teaching are appropriate activities for licensed nursing staff members

4. The nurse is reviewing the laboratory results for a patient with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider? 1. Serum potassium is 3.4 mEq/L (3.4 mmol/L). 2. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L). 3. Aspartate aminotransferase (AST) is 30 units/L (0.5 µkat/L). 4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L). Ans: 4 The patient's LDL level continues to be elevated and indicates a need for further assessment (e.g., the patient may not be taking the atorvastatin), a change in medication, or both. Although statin medications may cause rhabdomyolysis, which could increase BUN and potassium, the patient's BUN and potassium levels are not elevated. Although ongoing monitoring of liver function is recommended when statins are used, this patient's AST is normal.

45. A patient who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which patient information is most important for the nurse to communicate to the health care provider (HCP) before the procedure? 1. Blood glucose level is 144 mg/dL (8 mmol/L). 2. Cardiac monitor shows sinus bradycardia with a rate of 56 beats/min. 3. Patient reports chest pain that occurred yesterday. 4. Patient took metformin 500 mg this morning

4. Patient took metformin 500 mg this morning Ans: 4 Because use of metformin may lead to acute lactic acidosis when patients undergo procedures that use iodine-based contrast dye, metformin should be held for 24 hours before and 48 hours after coronary arteriogram. The arteriogram will need to be rescheduled. The other information will also be reported to the HCP but would not be unusual in patients with coronary artery disease.

19. The nurse has given morphine sulfate 4 mg IV to a patient who is having an acute myocardial infarction. When evaluating the patient's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) Ans: 4 The goal in pain management for the patient with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

13. At 9:00 PM, the nurse admits a 63-year-old patient with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the patient? 1. The patient was treated with alteplase about 8 months ago. 2. The patient takes famotidine for gastroesophageal reflux disease. 3. The patient has ST-segment elevations on the electrocardiogram. 4. The patient reports having continuous chest pain since 8:00 AM.

4. The patient reports having continuous chest pain since 8:00 AM. Ans: 4 Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are usually not recommended for patients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. F

7. When the nurse is monitoring a 53-year-old patient who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Three premature ventricular contractions (PVCs) in a row

4. Three premature ventricular contractions (PVCs) in a row Ans: 4 Three PVCs in a row indicate nonsustained ventricular tachycardia and are an indication to stop the testing to avoid a worsening dysrhythmia. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing.