Prep U Ch. 27 Management of Patients With Coronary Vascular Disorders

Which of the following is the analgesic of choice for acute MI?

Morphine sulfate

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include?

"Client will verbalize the intention to stop smoking." A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina.

A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?

"I should expect a low-grade fever and swelling at the site for the next week." Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?

"Removing the patch at night prevents drug tolerance while keeping the benefits." Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerine are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while you rest, there is less demand on the heart but not the primary reason for removing the patch.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?

"The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

The nurse is reviewing the results of a total cholesterol level for a patient who has been taking simvastatin (Zocor). What results display the effectiveness of the medication?

160-190 mg/dL Simvastatin (Zocor) is a statin Frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL

Heparin therapy is usually considered therapeutic when the patient's activated partial thromboplastin time (aPTT) is how many times normal?

2 to 2.5 The amount of heparin administered is based on aPTT results, which should be obtained in follow-up to any alteration of dosage. The patient's aPTT value would have to be greater than .5 to 1 times normal to be considered therapeutic. An aPTT value that is 2.5 to 3 times normal would be too high to be considered therapeutic. The patient's aPTT value would have to be greater than .25 to .75 times normal to be considered therapeutic.

A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many mL per hour will the nurse infuse this solution? Enter the correct number ONLY.

24 ml

A patient asks the nurse how long he will have to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse?

3 minutes Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally alleviates the pain of ischemia within 3 minutes.

A client with suspected acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?

4 to 6 hours Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to remove the femoral sheath when the partial thromboplastin time (PTT) is:

50 seconds or less. Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

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

60 minutes

The nurse has been asked to explain the cause of angina pain to a patient's family. Choose the best statement. The pain is due to:

A lack of oxygen in the heart muscle that causes the death of cells. Impeded blood flow, due to blockage in a coronary artery, deprives the cardiac muscle cells of oxygen thus leading to a condition known as ischemia.

Which nursing diagnosis is most significant in planning the care for a client with Raynaud's disease?

Acute Pain The hallmark symptom of Raynaud's Disease is pain related to the arterial insufficiency. Disturbed Sensory Perception associated with paresthesia can occur but is less significant than pain. Self-Care Deficit and Activity Intolerance can occur but less significant than Acute Pain.

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before completing the initial assessment is premature.

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

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

What ECG findings does the nurse observe in a patient who has had a myocardial infarction (MI)? (Select all that apply.)

An abnormal Q wave T-wave inversion ST-segment elevation The ECG changes that occur with an MI are seen in the leads that view the involved surface of the heart. The expected ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave (Fig. 27-5).

Which of the following terms refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

Angina pectoris Angina pectoris is a symptom of myocardial ischemia. Atherosclerosis is an abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumens. Atheromas are fibrous caps composed of smooth muscle cells that form over lipid deposits within arterial vessels. Ischemia is insufficient tissue oxygenation and may occur in any part of the body.

Which of the following methods to induce hemostasis after sheath removal post percutaneous transluminal coronary angioplasty (PTCA) is the least effective?

Application of a sandbag to the area Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding. Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site has been demonstrated to be effective and was the first method used to induce hemostasis post PTCA. Application of a pneumatic compression device post PTCA has been demonstrated to be effective.

After percutaneous transluminal coronary angioplasty (PTCA), the nurse suspects that a patient, who is on bed rest, may be experiencing the complication of bleeding. The nurse's initial action should be to do which of the following?

Apply manual pressure at the site of the insertion of the sheath. The immediate nursing action would be to apply pressure, which may stop the bleeding. If the bleeding does not stop, the health care provider needs to be notified.

A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response?

Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease?

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

You are caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?

Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure.

Which condition most commonly results in coronary artery disease (CAD)?

Atherosclerosis Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

You are presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?

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

When starting a client on oral or I.V. diltiazem (Cardizem), for which potential complication should the nurse monitor?

Atrioventricular block The chief complications of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reported reactions include flushing, nocturia, and polyuria, but not renal failure. Although flushing may occur, it's an adverse reaction, not a potential complication.

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol?

Atropine Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.

The nurse is caring for a client with Raynaud's disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes.

The nurse is caring for a client with Raynaud's disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

A 56-year-old male client with CAD kept his appointment to see a cardiologist for posthospitalization follow up. The client indicates that he thinks the diltiazem (Cardizem) has been making him nauseous. The nurse is aware that diltiazem (Cardizem) is categorized as which type of drug?

Calcium-channel blockers

Aortic stenosis remains asymptomatic for several decades. However, once a client becomes symptomatic for aortic stenosis, life expectancy without further treatment is only 2 to 3 years. What is the treatment of choice for symptomatic aortic stenosis?

Balloon valvuloplasty Additional treatment eventually becomes critical because average survival is 2 to 3 years once symptoms develop. Balloon valvuloplasty is an invasive, nonsurgical procedure to enlarge a narrowed valve opening. Balloon angioplasty, cardiac catheterization, and cardiac graft procedure are not indicated treatments for aortic stenosis.

A client is receiving nitroglycerin ointment (Nitro-Dur) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

Blood pressure 84/52 mm Hg Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately

Which diagnostic is a marker for inflammation of vascular endothelium?

C-reactive protein (CRP) C-reactive protein (CRP) is a marker for inflammation of vascular endothelium. LDL, HDL, and triglycerides are not marker of vascular endothelium inflammation. They are elements of fat metabolism.

A nurse is caring for a patient in the cardiovascular intensive care unit (CVICU) following a coronary artery bypass graft (CABG). Which of the following clinical findings requires immediate intervention by the nurse?

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

A patient has had cardiac surgery and is being monitored in the intensive care unit (ICU). What complication should the nurse monitor for that is associated with an alteration in preload?

Cardiac tamponade Preload alterations occur when too little blood volume returns to the heart as a result of persistent bleeding and hypovolemia. Excessive postoperative bleeding can lead to decreased intravascular volume, hypotension, and low cardiac output. Bleeding problems are common after cardiac surgery because of the effects of cardiopulmonary bypass, trauma from the surgery, and anticoagulation.

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

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

Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin?

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

A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client?

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

The analgesic of choice for a hospitalized patient with an MI is morphine sulfate. An important nursing responsibility, prior to administering morphine, is to do which of the following?

Count the respiratory rate for bradypnea. The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.

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

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

Which of the following is inconsistent as a condition related to metabolic syndrome?

Hypotension

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?

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

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time

Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction For a client recovering from CABG surgery, Decreased cardiac output is the most important nursing diagnosis; anesthetics or a long cardiopulmonary bypass time may depress myocardial function, leading to decreased cardiac output. Other possible causes of decreased cardiac output in this client include fluid volume deficit and impaired electrical conduction. Anxiety, Disabled family coping, and Hypothermia may be relevant but take lower priority at this time; maintaining cardiac output is essential to sustaining the client's life.

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

Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available.

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient?

Decreases the sinoatrial node automaticity Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and his family to expect which common symptom that typically resolves spontaneously?

Depression For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise family members that symptoms of depression don't always resolve on their own. They should make sure they recognize worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate physician notification.

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment

A female client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows:

Elevated troponin levels Troponin is present only in myocardial tissue; therefore, it is the gold standard for determining heart damage in the early stages of an MI. LDH1 and LDH2 may be elevated in response to cardiac or other organ damage during an MI. Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage during an MI. C-reactive protein, erythrocyte sedimentation rate, and the WBC count increase on about the third day following MI because of the inflammatory response that the injured myocardial cells triggered. These levels would not be elevated during the MI event.

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol (Lopressor), 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?

Heart Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

A nurse is monitoring the vital signs and blood results of a 53-year-old male patient who is receiving anti-coagulation therapy. Which of the following does the nurse identify as a major indication of concern?

Hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lowered hematocrit can imply internal bleeding.

A 62-year-old male client who works as a stockbroker reports chest pain and palpitations during and after his morning jogs. The client's family history includes CAD. His lipid profile reveals his LDL level to be 122 mg/dL. The nurse is aware that this client has which of the following?

High LDL level

Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.

High-density lipoprotein (HDL), 80 mg/dL A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.

When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality?

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

The nurse is caring for a patient who is having chest pain associated with a myocardial infarction (MI). What medication should the nurse administer intravenously to reduce pain and anxiety?

Morphine sulfate

Which of the following would be inconsistent as criterion of extubation in the patient who has undergone a coronary artery bypass graft (CABG)?

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

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025), the nurse suspects

Inadequate fluid volume

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (less than 25 mL per hour) with high specific gravity (greater than 1.025), the nurse suspects which of the following conditions?

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

Which of the following is the most important postoperative assessment parameter for patients undergoing cardiac surgery?

Inadequate tissue perfusion The nurse must assess the patient for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin.

A patient's elevated cholesterol levels are being managed with Lipitor, 40 mg daily. The nurse practitioner reviews the patient's blood work every 6 months before renewing the prescription. The nurse explains to the patient's daughter that this is necessary because of a major side effect of Lipitor that she is checking for. What is that side-effect?

Increased liver enzymes Myopathy and increased liver enzymes are significant side effects of the statins, HMG-CoA reductase inhibitors that are used to affect lipoprotein metabolism.

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.)

It is substernal in location. It is viselike and radiates to the shoulders and arms. It is sudden in onset and prolonged in duration Chest pain that occurs suddenly, continues despite rest and medication, is substernal, and is sometimes viselike and radiating to the shoulders and arms is associated with an MI. Angina pectoris pain is generally relieved by rest and nitroglycerin.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following?

Low blood pressure The patient receiving anticoagulation therapy should be monitored for signs and symptoms of external and internal bleeding, such as low blood pressure, increased heart rate, and decreased serum hemoglobin and hematocrit.

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

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

Upon discharge from the hospital, patients diagnosed with a myocardial infarction (MI) must be placed on all of the following medications except:

Morphine IV Upon patient discharge, there needs to be documentation that the patient was discharged on a statin, an ACE or angiotensin receptor blocking agent (ARB), and aspirin. Morphine IV is used for these patients to reduce pain and anxiety. The patient would not be discharged with IV morphine.

The nurse is caring for a male patient who is being evaluated for lipid-lowering medication. The patient's laboratory results reveal the following: Total cholesterol: 230 mg/dL, LDL: 120 mg/dL, and a triglyceride level of 310 mg/dL. Which of the following classes of medications would be most appropriate for the patient based on his laboratory findings?

Nicotinic acids The most appropriate class of medications based on the patient's laboratory findings would be nicotinic acids. This class of medications is prescribed for patients with: minimally elevated cholesterol and LDL levels or as an adjunct to a statin when the lipid goal has not been has not been achieved and triglyceride (TG) levels are elevated.

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

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

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?

Pallor Pallor is the initial symptom in Raynaud's followed by cyanosis and aching pain. Gangrene can occur with persistent attacks and interference of blood flow. Clubbing of the fingers is a symptom associated with chronic oxygen deprivation to the distal phalanges.

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome?

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

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having?

Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

The nurse, caring for a patient after cardiac surgery, is aware that fluid and electrolyte imbalance is a concern. Select the most immediate result that needs to be reported.

Potassium level of 6 mEq/L

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

Protamine sulfate

A client has had oral anticoagulation ordered. What should you monitor for when your client is taking oral anticoagulation?

Prothrombin time (PT) or international normalized ratio (INR) The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.

A client is being evaluated for coronary artery disease (CAD) and is scheduled for an electron beam computed tomography. The nurse understands that the primary advantage of this radiologic test is which of the following?

Quantifies calcified plaque The primary advantage of EBCT is to detect and quantify calcified plaque in the coronary arteries even before symptoms arise. EBCT is noninvasive and provides clearer images with less exposure to radiation than a CT scan but not the primary reason for use.

The nurse is part of a triage team that is assessing a patient to determine if his chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction is that the pain of angina is:

Relieved by rest and nitroglycerin

A 65-year-old male client with CAD has been prescribed a transdermal nitroglycerin patch. The nurse's instructions to the client would include which of the following? Select all that apply.

Store the patch in its original container when not in use. Remove the transdermal patch at night and reapply in the morning. Transdermal nitroglycerin systems are applied to the skin and slowly release nitroglycerin. Clients should be instructed to store the patch in its original container when not in use and keep tightly closed, remove the patch each night and reapply in the morning to prevent diminishing vasodilating effects, and expect possible side effects, such as headache, flushing, or nausea

A client was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?

Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn't be performed during an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.

Two female nursing assistants approach a nurse on a cardiac step-down unit to report that a client who experienced an acute myocardial infarction made sexual comments to them. How should the nurse intervene?

The nurse should explain that the client might have concerns about resuming sexual activity but is afraid to ask. Sometimes clients are concerned about resuming sexual activity but are afraid to ask. Making inappropriate sexual comments provides a forum for asking questions. It isn't necessary to report the incident to the nursing supervisor immediately without investigating the situation further. The client's call light must be answered in a timely fashion. More information is needed before assuming that the client is asking for extra attention.

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)?

The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?

To decrease workload of the heart Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and Bvitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction remains elevated for as long as 3 weeks?

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

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

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

Which of the following is also termed preinfarction angina?

Unstable Angina Preinfarction angina is also known as unstable angina. Stable angina has predictable and consistent pain that occurs on exertion and it relieved by rest. Variant angina is exhibited by pain at rest with reversible ST-segment elevation. In silent angina, there is evidence of ischemia, but the patient reports no symptoms.

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?

Vague symptoms Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.

A 23-year-old female client has been diagnosed with Raynaud's disease. The nurse teaches the client which of the following self-care strategies to minimize risks associated with this disease? Select all that apply.

Wear gloves to protect hands from injury when performing tasks. Do not smoke or stop smoking. Avoid over-the-counter decongestants and cold remedies The nurse instructs clients with Raynaud's disease to quit smoking, avoid over-the-counter decongestants, cold remedies, and drugs for symptomatic relief of hay fever because of their vasoconstrictive qualities, protect hands and feet from injury, and wear warm socks and mittens when going outdoors in the cold weather

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?

Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days

Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur?

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

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:

a drop in the client's heart rate. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of:

aspirin or clopidogrel (Plavix). fter PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Physicians order heparin for anticoagulation during this procedure; some physicians discharge clients with a prescription for long-term warfarin (Coumadin) or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn't required after PTCA because the procedure itself opens the vessel. The physician may order short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn't warranted. The client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn't necessary.

Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of:

myocardial necrosis. An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency department. In terms of serum testing, it's most important for the physician to order cardiac:

troponin. This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific indicators of myocardial damage than troponin.