Med Surg 1 Chapter 38
The nurse is providing health education to a patient with coronary artery disease after surgical intervention. What instructions should the nurse give to this patient? Select all that apply.
"Avoid exercising when your pulse increases more than 20 beats/min. Avoid straining activities Straining activities like lifting and pushups may make the sternum's healing process worse. Stopping exercise when the pulse increases to more than 20 beats/min will decrease the risk of injury and fatigue. Nitroglycerin is used in case of emergency (sudden rise in blood pressure) and should be carried by the patient. Outdoor exercise in good weather is refreshing. A patient's pulse should be checked prior to exercise, and if the pulse rate is higher than it should be, the patient should stop exercising. After exercise, the patient's pulse should be checked to avoid any complications such as shortness of breath and dizziness.
The nursing student is assisting with the care of a patient who has undergone coronary artery bypass grafting (CABG). Which statement by the student about the procedure indicates a need for further teaching by the supervising nurse?
"Best outcomes from CABG occur when coronary arteries have less than a 50% occlusion." In CABG, the vessels to be bypassed typically have 70% or more of the vessel blocked; bypassing vessels with lesser occlusion may result in early obstruction. CABG is used for left main coronary artery disease that is not amenable to stent placement. Quality of life rather than lifespan is improved with CABG. Ninety percent of internal mammary artery grafts remain patent for 12 years.
What should a patient do if he has new-onset angina at home?
"Ingest 4 baby aspirins 81 mg each." A patient with new-onset angina at home is advised to chew 325 mg of aspirin, or 4 baby aspirins, 81 mg each, immediately and then call 911. Ingesting 4 baby aspirins 85 mg each; 3 baby aspirins 81 mg each; and 3 baby aspirins 85 mg each, do not meet the recommended dose requirements.
A patient weighing 165 lbs reports having chest discomfort for the past 50 minutes. The primary health care provider prescribes thrombolytic therapy followed by aspirin and IV heparin. Subcutaneous administration of low-molecular-weight heparin (LMWH) was prescribed followed by the administration of IV heparin. What is the dose of heparin that the nurse should administer? Record your answer using a whole number. ______ mg
75 The dosage of LMWH is based on the weight of the patient (1mg/kg). 165 lbs is equal to 75 kg, so the dosage of LMWH for a patient weighing 165 lbs is 75 mg.
What medication is administered prior to nitrates to reduce headache discomfort?
Acetaminophen Acetaminophen is indicated for relief of headache prior to the administration of nitrates. Morphine is not indicated for treating headaches. Ibuprofen is not indicated for headaches in patients taking nitrates. Clopidogrel is not indicated for headaches
An older adult patient, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take?
Assess pulmonary artery wedge pressure Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative patients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.
Which drug is a beta blocker used to treat coronary artery disease (CAD)?
Carvedilol Carvedilol is a beta blocker used to treat CAD. It decreases the size of the infarct and the occurrence of ventricular dysrhythmias. Aspirin is an antiplatelet agent used to treat CAD that inhibits platelet aggregation and vasoconstriction, and decreases the occurrence of thrombosis. Clopidogrel and prasugrel are thienopyridines that prevent platelet aggregation, slowing the rate of clot formation, and are also used in the treatment of CAD.
A patient has just returned from coronary artery bypass graft (CABG) surgery. For which finding does the nurse contact the surgeon?
Chest tube drainage of 175ml last hour Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL per hour to the surgeon. Although hypothermia is a common problem after surgery, a temperature of 98.2° F is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Incisional pain of 6 on a scale of 0 to 10 is expected immediately after major surgery; the nurse should administer prescribed analgesics.
The nurse is assessing a patient who has experienced a myocardial infarction (MI). The health care provider is notified when the nurse notes which finding?
Cough with pink frothy, sputum Pink, frothy sputum; wheezing; and tachypnea are symptoms of acute pulmonary edema, a life-threatening form of left ventricular failure that requires immediate intervention. While dysrhythmia is a complication of MI, a slightly lower heart rate during sleep is not emergent. A urine output of 30 mL/hr is expected; a patient making 320 mL of urine over 8 hours is putting out 40 mL/hr, which is acceptable. Stating anxiety about one's diagnosis is positive coping and does not require notification of the provider.
The patient in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure?
Crackles in lung field Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles [1] [2] and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.
Which drug is an inotrope that may be used to maintain organ perfusion in a patient who had heart failure after a myocardial infarction (MI)?
Dobutamine Dobutamine is an inotrope that may be used to maintain organ perfusion in a patient who sustained heart failure after an MI. Dobutamine increases the force of cardiac contraction. Nitroglycerin and fenoldopam are nitrates that are used to maintain organ perfusion. Nitrates cause vasodilation of arteries and veins. Milrinone is also an inotrope, but it is also classified as a nitrate because of its vasodilation effects.
The nurse is caring for a patient with coronary artery disease (CAD) who has been prescribed metoprolol XR. What action does the nurse perform when caring for the patient?
Hold the medication if the heart rate is less than 50-60 beats/min The nurse should not administer metoprolol if the patient's heart rate is less than 50-60 beats/min because it is a beta blocker. A side effect of beta blockers is bradycardia, and this medication would further decrease the heart rate. Beta blockers are safe to take with sildenafil. Nitrates are not administered with sildenafil because fatal interactions occur between these drugs. Metoprolol XR is an extended-release medication and cannot be crushed; the capsule must be taken whole. Patients taking nitrates, not beta blockers, are taught to lie down on the bed after administration because an upright position intensifies hypotension, which can be fatal.
A patient has undergone percutaneous coronary intervention (PCI) through the right femoral artery and has received bivalirudin infusion during the procedure. What is the nurse's priority action when the patient returns?
Monitor insertion site for bleeding Bivalirudin is a direct thrombin inhibitor used during PCI; by inhibiting thrombin, bleeding may occur. Cough may be a symptom of heart failure, but is not a specific complication of the PCI. The urine output should be monitored as contrast is used during PCI, but observing for hemorrhage is the priority. A local anesthetic is used during PCI, and pain may indicate hematoma; however, observation for bleeding is essential as a large artery is entered for this procedure and anticoagulation is used.
Which statement by a patient scheduled for a percutaneous coronary intervention (PCI) indicates a need for further preoperative teaching?
My angina will be gone for good Reocclusion is possible after PCI. The patient is typically awake, but drowsy, during this procedure. PCI uses a balloon to widen the artery, and the patient will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.
When planning care for a patient in the emergency department, which interventions are needed in the acute phase of myocardial infarction? Select all that apply.
Nitroglycerin Morphine sulfate Oxygen Morphine is needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers like verapamil are used for angina, not for MI.
A patient comes to the emergency department with chest discomfort. Which action does the nurse perform first?
Obtain the patients description of chest pain A description of the chest discomfort must be obtained first, before further action can be taken. Pain medication and oxygen therapy are not the first priority in this situation; an assessment is needed first. Remaining calm and staying with the patient is important, but this is not the matter of highest priority.
A patient has sustained an ST-segment myocardial infarction (STEMI) to the anterior wall and new-onset third-degree heart block. Which intervention does the nurse anticipate will be prescribed by the health care provider?
Pacemaker Third-degree heart block is a complication of a large myocardial infarction resulting in profound bradycardia; a pacemaker is indicated to restore hemodynamic stability. Defibrillation is indicated in patients with ventricular fibrillation or pulseless ventricular tachycardia. Cardioversion (synchronized electrical energy directed to the heart) is used to correct rapid rhythms such as atrial fibrillation, atrial flutter, or supraventricular tachycardia. Heparin infusion is used in patients with MI to maintain the patency of the coronary artery after thrombolysis or in acute coronary syndrome.
Two patients suffering from myocardial infarction visit the hospital. The clinical data of the patients are mentioned below. Both patients have similar complaints, but were prescribed different treatments. What are the reasons for this? Select all that apply.
Patient B has postpericardiotomy syndrome Patient A has sternal osteomyelitis Mediastinitis, sternal osteomyelitis, and postpericardiotomy syndrome are postoperative complications of CABG. Patient A was diagnosed with sternal osteomyelitis, so this patient is treated with IV antibiotics for 4 to 6 weeks. Patient B was diagnosed with postpericardiotomy syndrome, and because postpericardiotomy is self-limiting, it may not require any treatment. Patient A with mediastinitis is treated with surgical debridement, irrigation, and IV antibiotics. Patient B with sternal osteomyelitis should be treated with IV antibiotics for 4 to 6 weeks, however, it is mentioned that patient B's condition is self-limiting, and patient A with postpericardiotomy syndrome may not require any treatment because it is self-limiting.
The nurse in the coronary care unit is caring for a group of patients who have had myocardial infarction. Which patient does the nurse see first?
Patient with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the patient with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The patient with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The patient's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.
The patient presents to the emergency room with severe chest pain. After administration of two sublingual nitroglycerin tablets, the patient is now reporting pain of 2 on a scale of 1-10. What action by the nurse is priority?
Prepare to administer a third nitroglycerin tablet Patients can receive three nitroglycerin tablets in 5-minute increments to treat chest pain. The patient indicated pain relief with the first two pills, which would indicate a need to give a third. There is no indication of a need to recheck cardiac enzymes or to repeat an electrocardiogram. It is good to continue to monitor the patient, but the priority is administering nitroglycerin.
The nurse is providing care to a patient two days after the patient underwent cardiac surgery. Assessment findings include the patient reporting chest pain that intensifies during inspiration, an increased white blood cell count, elevated body temperature, and irregular heart rate. What is the likely cause of these symptoms?
Presence of blood in the pericardial sacs The patient is experiencing pleural pain, chest pain, elevated body temperature, increased while blood cell count, and dysrhythmias, which are all indications of postpericardiotomy syndrome. This syndrome may present days or weeks after cardiac surgery and occurs as a result of accumulating blood in the pericardial sac. Glycoprotein IIb may increase risk of bleeding or hypersensitivity reaction. Milrinone may cause dieresis and hypotension. These drugs are not associated with the symptoms the patient is experiencing. Postpericardiotomy syndrome is not a normal consequence and needs immediate medical attention.
A patient diagnosed with evolving myocardial infarction abruptly develops ventricular fibrillation. Which is the priority action for the nurse at this time?
Provide defibrillation The priority for ventricular fibrillation is immediate defibrillation; the patient is apneic, pulseless, and breathless secondary to chaotic and ineffective heart rhythm, and this must be terminated with immediate electrical shock. Monitoring the electrocardiogram (ECG) delays the required defibrillation and restoration of cardiac output. While nitroglycerin is used for myocardial infarction, it has no antidysrhythmic property and will not terminate ventricular fibrillation. Since the patient with ventricular fibrillation is apneic, administering oxygen will not be of use.
The nurse is caring for a patient 36 hours after coronary artery bypass grafting (CABG), with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the patient to bed?
Respiratory rate 28/min Tachypnea and tachycardia reflect activity intolerance; activity should be terminated. Pulse 60 and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Pain with activity after surgery is anticipated; pain medication should be available.
The nurse is assessing a patient with chest pain to evaluate whether the patient is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI?
Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.
What medications should the nurse assess the patient for prior to administering nitroglycerin for chest pain? Select all that apply.
Tadalafil and sildenafil They are phosphodiesterase inhibitors used for treatment of erectile dysfunction. When given with nitroglycerin, they can cause profound hypotension. Cardizem, carvedilol, and metoprolol are not contraindicated with administration of nitroglycerin.
After receiving change-of-shift report in the coronary care unit, which patient does the nurse assess first?
The patient with acute coronary syndrome who has a 3-pound weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this patient needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the patient with dyspnea is taken care of. The patient with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the patient has a normal heart rate; the patient with dyspnea should be seen first.
A patient undergoing coronary artery bypass grafting (CABG) asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct?
These arteries remain open longer Mammary arteries remain patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts
When assessing a patient with evolving myocardial infarction (MI), for which associated symptom should the nurse be alert?
Vomiting In addition to chest pain, patients sustaining MI may also display dyspnea; ashen, cool, and clammy skin; diaphoresis; nausea, vomiting or epigastric pain; anxiety; and feeling of impending doom or dizziness. Leg pain may occur with fracture or deep vein thrombosis. Denial is the typical response to MI; depression may occur after an MI. An S1 heart sound or "lub" should be present at all times.
