33: CAD and ACS

Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy?

"Heparin will help prevent blood clots from forming in your heart chambers."

Drotrecogin alfa (xigris)

anti-inflammatory, antithrombotic agent given in septic shock

nitroglycerin

"NTG" - in-patient STEMI dose: 0.4mg SL q5min x3 doses total - IV NTG: if angina not relieve SL or hypertensive - outpatient: 0.4 mg SL x1 dose, call EMS if not relieved after 5 min

After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is ______________

"Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."

clopidogrel dosing

1. Post-fibrinolytics: - LD if <75 yo: *300 mg x1 * 2. s/p PCI: - *LD: 600 mg PO* 3. NSTEMI PCI: - LD: *600 mg PO* 4. NSTEMI Medical Management: - LD: *300-600 mg* PO 5. MD: 75 mg PO daily for 12 months

4 situations in which to avoid use of nitrates

1. hypotension 2. RV infarction 3. aortic stenosis 4. phosphodiesterase inhibitor in last 24 hours

Maintenance dose of Prasugrel

10 mg qd

Loading dose of high bolus dose tirofiban

25mcg/kg IV

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a a. thrill. b. bruit. c. murmur. d. normal finding.

ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? a. Insert an IV catheter. b. Administer oral sedative medications. c. Teach the patient about the procedure. d. Confirm that the patient has been fasting.

ANS: C The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary

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

ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).

Oral Antiplatelets

ASA, Clopidogrel, Prasugrel, Ticagrelor, Ticlodipine , Vorapaxar

GPIIbIIIa

Abciximab, Tirofiban, Eptifibatide

Niacin Mechanisms

Acts in the liver/adipose tissue to inhibit synthesis of triglycerides and decreases production of VLDL's

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? Chronic stable angina Left-sided heart failure Coronary artery disease Acute myocardial infarction

Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

tirofiban

Aggrastat - Glycoprotein IIb/IIIa Inhibitor - Duration: 18-24 hrs post-PCI - *Dose adjust CrCl < 30 mL/min*

Thrombolytics

Alteplase, Reteplase, Tenecteplase

Class 3- Potassium Channel Blockers

Amiodarone Dofetilide Sotalol

Calcium Channel Blockers

Amlodipine Diltiazem Nicardipine Nifedipine Verapamil

RAAS Suppressants

Angiotensin-Converting Enzyme (ACE) Inhibitors Angiotensin 2 Receptor Blockers (ARB's) Aldosterone Antagonists Calcium Channel Blockers Direct-Acting Vasodilators Organic Nitrates

A few days after an acute MI, a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first?

Auscultate the heart sounds.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? A Dehydration B Paralytic ileus C Atrial dysrhythmias D Acute respiratory distress syndrome

C Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

IV P2Y12

Cangrelor

Angiotensin-Converting Enzyme (ACE) Inhibitors

Captopril Enalapril Lisinopril

Drugs that affect myocontractility

Cardiac Glycosides

Alpha/Beta Blockers

Carvedilol Labetalol

When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse?

Chest pain level 8 on a 10-point scale

Bile-Acid Sequestrants

Cholestyramine

Antiplatelet (P2Y12 Inhibitor)

Clopidogrel (Plavix)

Oral P2Y12

Clopidogrel, Prasugrel, Ticagrelor

carvedilol

Coreg - beta-blocker - *MD: 3.125-50 mg PO BID w/ meals*

Action of Fibric Acid Derivatives (Gemfibrozil, Fenofibrate)

DECREASE VLDL and triglycerides. INCREASE HDL

How is eptifibatide dosed?

DOUBLE BOLUS 180 mcg/kg IV bolus--> 2mcg/kg/min rate Then 2nd bolus after 10 min

Anticoagulant (Low molecular weight heparin)

Enoxaparin (Lovenox)

Anticoagulants Enoxaparin (Lovenox) Heparin (Heparin) Warfarin (Coumadin)

Enoxaparin- Low Molecular Weight Heparin (LMWH)

d

For which of the following antilipemic medications would the nurse question an order in a patient with cirrhosis of the liver? A. Niacin (Nicobid) B. Ezetimibe (Zetia) C. Gemfibrozil (Lopid) D. Atorvastatin (Lipitor)

d

For which of the following is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease D. Acute myocardial infarction

ACE inhibitors

Helps prevent ventricular remodeling in CHF

Positive inotropic agent

Increases contractility but increases myocardial O2 consumption

Clopidogrel

Indications:

Aspirin

Indications: Analgesic, antiinflammatory, antipyretic, antiplatelet. Mechanism of Action: Inhibits cyclooxygenase in the platelet irreversibly so that the platelet cannot regenerate this enzyme. Therefore, the effects of aspirin last the lifespan of a platelet, or 7 days.

Warfarin:

Indications: Thromboprevention and treatment of DVT, PE, atrial fibrillation, post-MI status Mechanism of action: Inhibits vitamin K synthesis by bacteria in the GI tract. --> Inhibiting factors 2, 7, 9, 10 (vitamin-K clotting factors) Contraindications: PREGNANCY Adverse effects: Bleeding, lethargy, muscle pain, purple toes Administering: MONITOR: PT/INR --> INR: 1 (without warfarin) 2-3.5 (with warfarin) Toxicity and management: First step: discontinue. Second: (situation-dependent)... If serious enough --> Vit. K IV works w/in 6 hours. Recommended: use the lowest amount of vitamin k that is possible to stop the bleeding BECAUSE Once vit. K is given, warfarin resistance will occur for up to 7 days and the pt. cannot be anticoagulated by warfarin for that time period.

Class 1-Sodium Channel Blockers

Lidocaine Procainamide Quinidine

Ezetimibe SE

Myopathy Rhabdomyolysis Hepatitis Pancreatitis Thrombocytopenia

A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take?

Obtain and apply the transcutaneous pacemaker (TCP).

Drugs used to treat coronary artery constriction (Angina)

Organic Nitrates Beta Adrenergic Blockers Calcium Channel Blockers Thrombolytics

In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the __________________

PR interval.

Nitro Variant Angina

Prevents/relaxes spasm in coronary arteries increases oxygen supply

IV Morphine

Relieves anxiety and decreases afterload

Clopidogrel SE

Serious GI bleeds Toxic epidermal necrolysis Thrombotic thrombocytopenia purpura Neutropenia

ASA

Suppresses platelet aggravation by causing irreversible inhibition of Cyclooxygenase

Other drugs used for heart failure

Synthetic B-Naturetic Peptide (BNP)

The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider?

The lungs have crackles audible to the midline.

Anticoagulant

Unfractionated Heparin

Nitrates

Vasodilator to get more BF; can cause headaches; BP can bottom out

Antiplatelet (PAR-1 Antagonist)

Vorapaxar (Zontivity)

a

Which of the following individuals would the nurse identify as having the highest risk for CAD? A. A 45-year-old depressed male with a high-stress job B. A 60-year-old male with below normal homocysteine levels C. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels D. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

lisinopril

Zestril - initial dose: 5mg PO daily - target dose: 20-40 mg PO daily

when should platelet GP 2b/3a inhibitors be used

for patients undergoing early catheterization (within 4 hours)

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? "I will replace my nitroglycerin supply every 6 months." "I can take up to five tablets every 3 minutes for relief of my chest pain." "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

"I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, ________________

"I will have incisions in my leg where they will remove the vein."

Which of these statements made by a patient after the nurse has completed teaching about the TLC diet indicates that further teaching is needed?

"I will miss being able to eat peanut butter sandwiches."

The nurse instructs a 68-yr-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement? "Omega-3 fatty acids are helpful in reducing triglyceride levels." "I should check with my physician before I start taking any herbal products." "Herbal products do not go through as extensive testing as prescription drugs do." "I will take garlic instead of my prescription medication to reduce my cholesterol."

"I will take garlic instead of my prescription medication to reduce my cholesterol." Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, _______________

"I won't lift the arm on the pacemaker side up very high until I see the doctor."

In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? "What precipitated the pain?" "Has the pain changed this time?" "In what areas did you feel this pain?" "What is your pain level on a 0 to 10 scale?"

"In what areas did you feel this pain?" Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy?

"What time did your chest pain begin?"

A patient who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is, _____________

"You had a serious abnormal heart rhythm, which treatment was able to reverse."

Nitroglycerin

- *Rx for ALL ACS patients* - SL or spray - call 911 if no relief after 5 min - sit down (HA, dizziness, tingling) - store in cool, dry place

unfractionated heparin

- *preferred initial STEMI anticoagulation* - alternative NSTEMI anticoagulation - NSTEMI dose: 1. LD: *max 4000 units* (60 units.kg IV) 2. MD: *max 1000 units/hour* (12 units/kg/hr IV)

Therapeutic approaches to NSTEMI/unstable angina

- Anti-ischemic therapy: because of narrowed vessels (oxygen, vasodilators, beta blockers, morphine, ACEI) - Anti-platelet therapy: preventing growth of clot/progression to STEMI/death (antiplatelet agents, anticoagulants)

3 pharmacologic approaches for thromboembolic disorders

- Antiplatelet meds: interfere with platelet aggregation - Anticlotting meds/anticoagulants: interfere with clotting cascade - Thrombolytics: lyse thrombi

Dabigatran etexilate

- Class: anticoagulant - Indication: prevention of systemic embolism/stroke in patients with a-fib; DVT/PE treatment/prohylaxis of recurrent DVT/PE, post-op prophylaxis of recurrent DVT/PE, postop prohylaxis of thromboembolism - MOA: reversible direct thrombin inhibitor; binds to free thrombin/thrombin bound to clots - AE: bleeding, gastritis-like complaints - Interactions: P-glycoprotein inhibitors/inducers, anticoagulants - Contraindications: active bleedings, mechanical prosthetic heart valve - Antidote/reversal agent: idarucizumab *Med is unstable when exposed to moisture *Prodrug (converted in plasma, gut, liver)

Warfarin

- Class: anticoagulant - Indication: prevention of thrombosis associated with DVT/PE, prosthetic valves, a-fib, hx of DVT/PE - MOA: prevents active vitamin K regeneration (reduces levels/functionality of vitamin K dependent clotting factors (II, VII, IX, X) - AE: bleeding - Contraindications: pregnancy - Interactions: antiplatelets, anticoagulants, vitamin K - Antidote: vitamin K, 4F-PCC *Response to warfarin affected by variant alleles of 2 genes

Rivaroxaban

- Class: anticoagulant - Indication: prevention/treatment of DVT/PE; prevention of recurrent DVT/PE, stroke in a-fib, postop DVT prevention - MOA: factor Xa inhibitor - AE: bleeding - Interactions: anticoagulants, P-glycoprotein/CYP3A4 inducers/inhibitors Contraindicated: active bleeding - No antidote/reversal

Enoxaparin

- Class: anticoagulant - Indication: treatment/prevention of DVT, ischemic complications of acute MI, post-thrombolysis - MOA: increases antithrombotic activity; preferentially inactivates factor Xa - AE: bleeding - Interactions: antiplatelets, anticoagulants - Caution: platelets with bleeding risk, spinal/epidural catheter - Antidote: protamine sulfate

Heparin

- Class: anticoagulant - Indication: treatment/prevention of thrombosis, prevention of post op venous thrombosis, open heart surgery, dialysis - MOA: increases antithrombin activity 1000x - AE: bleeding - Interactions: antiplatelets, anticoagulants - Caution: patients with bleeding risk, spinal/epidural catheter, pregnancy - Antidote: protamine sulfate

Eptifibatide

- Class: antiplatelet - Indication: ACS managed medically/with PCI - MOA: glycoprotein IIb/IIIa receptor inhibitor (no receptor for fibrinogen inhibits platelet aggregation) - AE: bleeding - Interactions: antiplatelet drugs, heparin, thrombolytics, aspirin, NSAIDs - Contraindicated: 6 weeks prior to surgery, bleeding/stroke in past 30 days, severe hypertension, hx of hemorrhagic stroke

Clopidogrel

- Class: antiplatelet - Indication: ACS, prevent stroke, MI, death in patients with recent MI, stoke, PAD - MOA: irreversible ADP receptor (P2Y12) antagonist (inhibits platelet aggregation for life of platelet - AE: bleeding, abdominal pain, rash - Interactions: proton-pump inhibitors (inhibit CYP2C19) *Prodrug (converted by CYP2C19)

Aspirin

- Class: antiplatelet - Indication: primary/secondary prevention of MI, ischemic stroke, TIA, angina, acute MI - MOA: irreversibly inhibits COX-1 > COX-2 - AE: bleeding, renal dysfunction, Reyes syndrome - Interactions: warfarin, anticoagulants, glucocorticoids, alcohol, ACE inhibitors, ARBs - Contraindications: don't give to children under age 18 *325 mg aspirin should be chewed if MI is suspected

Nitroglycerin

- Class: organic nitrate - Indication: angina - MOA: vasodilation via NO; reduces oxygen demand of heart by decreasing preload - AE: headache, orthostatic hypotension, cardiac vasospasm - Interactions: antihypertensive, phosphodiesterase type 5 inhibitors - Contraindications: patients taking PDE5 inhibitors *IV (administered in glass bottle with special tubing)

Alteplase

- Class: thrombolytic/fibrinolytic - Indication: acute MI, PE, ischemic stroke - MOA: activation of fibrin-bound plasminogen - AE: bleeding - Interactions: antiplatelets, anticoagulants - Caution: uncontrolled HTN, remote stroke, recent trauma, post surgery, active PUD, pregnancy - Contraindications: prior hemorrhagic stroke, ischemic stroke in last 3 months, intracranial neoplasm, internal bleeding, aortic dissection

Heparin-induced thrombocytopenia (HTT)

- Disorder caused by formation of antibodies to complexes of platelet factor 4/heparin - Antibodies bind to PF4-heparin complexes on platelet surface/induce platelet activation - Activated platelets increase release/surface expression of PF4 (creates positive feedback loop) - Platelet activation causes release of procoagulant platelet microparticles, thrombosis, platelet consumption, thrombytopenia - Can cause venous/arterial thromboses

Thrombolytics

- Lyse an existing thrombus - Used to treat STEMI, ischemic stroke, PE

clopidogrel

- P2Y12 inhibitor - Indication: All STEMI/NSTEMI patients - only agent available after fibrinolytic therapy - *Prodrug metabolized by CYP2C19*: genetic polymorphisms may dec. activity

Therapeutic approaches to STEMI

- Restore blood flow (PCI, lysing existing clot, anticoagulant therapy) - Reduce cardiac oxygen demand/increase oxygen supply; reduce workload of stressed heart (selective beta blockers, oxygen, morphine, nitroglycerin) - Reduced pain (will also reduce SNS response) (morphine sulfate) - Limit ventricular remodeling (sequela of MI) (ACEI)

aspirin

- STEMI Initial Dose: 162-325 mg *chewed* - MD: 81 mg PO daily indefinitely

Antiplatelet agents/anticoagulants

- Suppress thrombosis (thrombus formation) but don't dissolve clots - Used to prevent/manage DVT, a-fib sequelae, hypercoagulable states, supplement post-thrombolytic therapy/stent placement

morphine

- Use: STEMI with refractory chest pain - dose: 2-4 mg IV q5-15 min PRN - a venous and arterial dilator, so decrease workload of heart

enoxaparin

- alternative initial STEMI anticoagulation - *preferred NSTEMI anticoagulation* - NSTEMI Dose: 1. 1 mg/kg SQ Q12hrs 2. CrCl < 30 ml/min: *1 mg/kg SQ daily*

bivalirudin

- anticoagulant - use: PCI anticoagulation - *must be dose adjusted w/ CrCl <30 ml/min* - may be used if Hx of HIT

streptokinase

- non-fibrin specific fibrinolytic

cangrelor

- only IV antiplatelet for s/p PCI - only given during PCI - CI: given with glycoprotein inhibitor - dec. risk of periprocedural MI vs. clopedigrel

rosuvastatin

- statin - high intensity: 20-40mg - moderate intensity: 5-10 mg

atorvastatin

- statin - high intensity: 40-80 mg - moderate intensity: 10-20 mg

) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and β-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

...

Continuous Infusion Rate of Abciximab

0.125 mcg/kg/min

Cont. Infusion Rate of Tirofiban

0.15mcg/kg/min

Loading dose of Abciximab

0.25mg/kg IV bolus

When a patient requires defibrillation, in which order will the nurse accomplish the following steps?

1 Turn the defibrillator on. 2 Select the appropriate energy level 3 Place the paddles on the patient's chest. 4 Check the location of other personnel and call out "all clear." 5 Deliver the electrical charge.

The nurse provides discharge teaching to a patient who is newly diagnosed with coronary artery disease (CAD). Which statement made by the patient indicates understanding of the dietary modifications that need to be implemented after discharge home? 1. "I will not eat bacon or any pork products." 2. "I will eat only fried eggs instead of boiled eggs." 3. "I may continue to enjoy French fries with hot dogs." 4. "I will drink no more than one glass of whole milk per day."

1. "I will not eat bacon or any pork products." Nutritional guidelines recommended for the patient with CAD include a low-cholesterol and low-fat diet; therefore the patient has to avoid bacon and any pork products. Egg yolk is high in cholesterol and the patient with CAD has to avoid fried food. French fries are high in fat because of their preparation process. Low-fat or nonfat milk is recommended for the patient with CAD.

Which drug prevents platelet aggregation by inhibiting cyclooxygenase? 1. Aspirin 2. Heparin 3. Abciximab 4. Clopidogrel

1. Aspirin Aspirin produces antiplatelet activity by inhibiting cyclooxygenase, which in turn produces thromboxane A 2, a potent platelet activator. Heparin prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin. Abciximab prevents binding of fibrinogen to platelets, thereby blocking platelet aggregation. Clopidogrel acts by inhibiting the adenosine diphosphate receptor on the platelet cell membrane. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse is caring for a patient with a myocardial infarction. The health care provider prescribes an intravenous infusion of alteplase. What is the priority nursing intervention during the administration of this medication? 1. Assess neurologic status. 2. Observe for bleeding gums. 3. Monitor blood pressure for orthostatic changes. 4. Apply a pressure dressing to intravenous (IV) insertion site.

1. Assess neurologic status. Assessment for changes in neurologic status is the priority nursing intervention because this may indicate a cerebral bleed. Gingival or bleeding gums are expected with thrombolytic therapy and are controlled by applying ice packs. Application of a pressure dressing to the IV insertion site is not done until evidence of bleeding is noted. Monitoring blood pressure for orthostatic changes is necessary with the use of short-acting nitrates.

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication? 1. Dysrhythmias 2. Anxiety and fear 3. Metabolic acidosis 4. Medication side effects

1. Dysrhythmias The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. The nurse should also be alert for increased anxiety, which may cause pain and lead to a secondary infarction. Anxiety and fear are highly likely but secondary in importance to monitoring the patient for dysrhythmias. Metabolic acidosis and reactions to new medications are not likely but should still be included as part of overall assessment of the patient.

A nurse teaches a patient about strategies to prevent angina caused by coronary artery disease. The nurse tells the patient that if a heavy meal is eaten, to rest for 1 to 2 hours after the meal. What is the rationale for this instruction? 1. Eating a heavy meal would divert more blood to the gastrointestinal system. 2. Heavy meals cause obesity and increase the susceptibility to myocardial ischemia. 3. Eating a heavy meal can cause physical inactivity, which could precipitate angina. 4. Heavy meals cause excessive heat production, which leads to peripheral vasodilation.

1. Eating a heavy meal would divert more blood to the gastrointestinal system. The digestive system requires more blood supply for a longer period of time to digest heavy meals. Therefore blood is diverted to the gastrointestinal system, which causes reduced blood supply to the myocardium. Physical inactivity does not cause an anginal attack; angina can be precipitated by physical exertion. Eating heavy meals causes obesity in due course of time, and this increases the susceptibility of an individual to have coronary artery disease. This is not a valid reason here, because the patient already has coronary artery disease. Eating heavy meals does not cause peripheral pooling of blood.

The nurse is preparing an initial care plan for a patient that presents with chest pain. What is the priority nursing intervention? 1. Monitoring the patient's ECG 2. Discussing the losses associated with chronic illness 3. Encouraging verbalization of feelings, perceptions, and fears 4. Advising the patient to avoid heavy meals and extreme weather conditions

1. Monitoring the patient's ECG A patient with chest pain may have acute coronary syndrome. The priority is to stabilize the patient, determine the plan of care, and prevent complications. Ongoing care should include continuous ECG monitoring. The nurse should help the patient with anxiety and stress to work on the losses due to chronic illness to prevent sudden depression-related cardiac workload. A patient with chronic stable angina is advised to avoid heavy meals and extreme weather to reduce the probability of symptoms. The nurse should encourage verbalization of feelings, perceptions, and fears that increases workload on heart. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Cardiac biomarker levels are being evaluated for a patient who is suspected of having a myocardial infarction (MI). The nurse recognizes that which biomarker lacks specificity and that its role in diagnosing an MI is limited? 1. Myoglobin 2. Creatine kinase-MB (CKMB) 3. Cardiac-specific troponin I (cTnI) 4. Cardiac-specific troponin T (cTnT)

1. Myoglobin Myoglobin is a serum cardiac marker that is released into the circulation within two hours after a myocardial infarction (MI). Myoglobin's role in diagnosing MI is limited because it lacks cardiac specificity. Creatine kinase-MB (CKMB) levels begin to rise about six hours after an MI, are specific to myocardial cells, and help quantify myocardial damage. Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) are highly specific indicators of MI.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? 1. Oxygen, nitroglycerin, aspirin, and morphine 2. Aspirin, nitroprusside, dopamine, and oxygen 3. Nitroglycerin, lorazepam, oxygen, and warfarin 4. Oxygen, furosemide, nitroglycerin, and meperidine

1. Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Furosemide, meperidine, nitroprusside, dopamine, lorazepam, and warfarin may be used later in the patient's treatment. STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

Cardiac Glycosides

Digoxin

A patient experiences anginal pain. What is an appropriate nursing intervention? 1. Position the patient upright and supply oxygen. 2. Encourage the patient to perform isometric exercises. 3. Place the patient in recumbent position during the attack. 4. Recommend a salt-rich diet to prevent orthostatic hypotension.

1. Position the patient upright and supply oxygen. A patient with angina should be placed in an upright position and supplied oxygen to provide comfort and to attain an appropriate amount of oxygen in blood unless contraindicated. A recumbent positioning of the patient may precipitate the attack. Isometric exercises are stressful and may exacerbate the symptoms by increasing the cardiac workload. Salt and saturated fat foods are restricted in the patient to prevent further complications.

The nurse assesses an older patient for risk factors for coronary artery disease (CAD). What question should the nurse ask the patient? 1. What is your BMI number? 2. Did you receive a pneumococcal vaccine? 3. When did you last have a bowel movement? 4. Did you travel abroad within the last 12 months?

1. What is your BMI number? Risk for CAD increases with obesity, which is defined as a BMI more than 30 kg/m 2. Constipation is not a risk factor for CAD. Traveling abroad to underdeveloped countries is a risk factor for infectious disease, but not for CAD. Pneumococcal vaccine protects the elderly patient from pneumonia, but not from CAD.

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which population has the highest incidence of CAD? 1. White male 2. Hispanic male 3. African American male 4. Native American female

1. White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in 35-year-old and under people, and have major modifiable risk factors, such as diabetes.

5 contraindications for beta blocker use

1. active bronchospasm 2. severe bradycardia 3. heart block > 1st degree 4. pulmonary edema 5. hypotension

After an MI, what should the patient leave the hospital with?

1. aspirin 2. P2Y12 receptor blocker 3. beta blocker 4. ACE inhibitor 5. statins

2 early hospital anti-platelet interventions after ACS

1. clopidogrel (or prasugrel or ticagrelor) 2. aspirin

5 early hospital anti-ischemic interventions after ACS

1. oxygen 2. nitrates 3. beta blockers 4. ACE inhibitors if EF<40% 5. statins

4 early hospital anticoagulant interventions after ACS

1. unfractionated heparin 2. enoxaparin 3. bivalirudin 4. fondaparinux

Loading dose of Ticagrelor

180mg

Class 4- Calcium Channel Blockers

Diltiazem Verapamil

The nurse is providing teaching to a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? Delegated to the primary care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient Accomplished by providing the patient with written material

Discussed along with other physical activities Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

5-10 mcg/kg/min

Dopamine dose to increase cardiac contractility

2-5 mcg/kg/min

Dopamine dose to increase renal perfusion

>10 mcg/kg/min

Dopamine dose which promotes vasoconstriction

Alpha 1 Adrenergic Blockers

Doxazosin Terazosin

prasugrel

Effient - P2Y12 Inhibitor - Indication: STEMI/NSTEMI pts *undergoing PCI* - 10 mg daily - duration: at least 12 months - Black Box: *significant/fatal bleeding* - no DDIs

The nurse prepares a discharge teaching plan for a 44-yr-old male patient who has recently been diagnosed with coronary artery disease (CAD). Which risk factor should the nurse plan to focus on during the teaching session? Type A personality Elevated serum lipids Family cardiac history Hyperhomocysteinemia

Elevated serum lipids Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

Antiplatelet (GP IIb/IIIa Inhibitor)

Eptifibatide (Integrilin)

Class 2- Beta-Adrenergic Blockers

Esmolol Propranolol

Others (Antilipidemics)

Ezetimibe

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? 1. "I will replace my nitroglycerin supply every six months." 2. "I can take up to five tablets every three minutes for relief of my chest pain." 3. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." 4. "I will take the nitroglycerin 10 minutes before a planned activity that usually causes chest pain."

2. "I can take up to five tablets every three minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after five minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every five minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

A nurse provides discharge teaching to a patient prescribed nitroglycerin sublingual tablets for the treatment of chronic stable angina. Which statement made by the patient indicates the need for further teaching? 1. "The sublingual tablets will expire six months from the time the bottle is opened." 2. "I will put the bottle in my front or back pant pockets before I leave the house." 3. "I can use this medication before exercising to prevent angina from occurring." 4. "Possible side effects include a warm feeling, headache, or lightheadedness.

2. "I will put the bottle in my front or back pant pockets before I leave the house." Sublingual nitroglycerin should not be stored in pant pockets because body heat can cause degradation of the nitroglycerin tablets. Flushing (warm feeling), headache, or dizziness (lightheadedness) may occur following sublingual nitroglycerin administration. Sublingual nitroglycerin can be used prophylactically before starting an activity that is known to cause an anginal attack. Sublingual nitroglycerin tablets tend to lose potency once the bottle has been opened; therefore it should be replaced every six months.

The nurse provides information to a patient about preventing coronary artery disease (CAD) by maintaining healthy serum low-density lipoproteins (LDL) and high-density lipoprotein (HDL) levels. The nurse should include what goals? 1. Decreased LDLs; decreased HDLs 2. Decreased LDLs; increased HDLs 3. Increased LDLs; increased HDLs 4. Increased LDLs; decreased HDLs

2. Decreased LDLs; increased HDLs Low-density lipoproteins (LDLs) contain more cholesterol than any other lipoprotein and have an attraction to arterial walls, whereas high-density lipoproteins carry lipids away from the arteries to the liver for metabolism and prevent lipid accumulation within the arterial walls. Therefore increasing high-density lipoprotein (HDL) levels and decreasing low-density lipoprotein (LDL) levels are most helpful in lowering the patient's risk of coronary artery disease. The nurse should not advise the patient to decrease high-density lipoproteins or increase low-density lipoprotein levels, because these actions would be counterproductive. STUDY TIP: In the first pass through the exam, answer what you know and skip what you do not know. Answering the questions you are sure of increases your confidence and saves time. This is buying you time to devote to the questions with which you have more difficulty.

The nurse recognizes indications of unstable angina if a patient experiences what symptoms? 1. Dyspnea, hyperglycemia, and polyuria 2. Nausea, indigestion, and shortness of breath 3. Peripheral edema and decreased urinary output 4. Confusion, dysrhythmias, and difficulty breathing

2. Nausea, indigestion, and shortness of breath A patient experiencing fatigue, indigestion, and shortness of breath may be experiencing an unstable anginal attack. A patient experiencing dyspnea, hyperglycemia and polyuria may have diabetes. A patient with peripheral edema and a decreased urine output may have right ventricular dysfunction or heart failure due to UA or coronary artery disease. Altered mental status (confusion), difficulty in breathing, dizziness, and dysrhythmias are observed in elder patients with UA. Test-Taking Tip: A patient should never neglect any signs of myocardial infarction. Educating the public, especially females, is important, to identify the complications early.

Which statement made by the student nurse indicates effective learning regarding the instructions to be given to a patient that receives a prescription for nitroglycerin? 1. "I should direct the patient to inhale the spray containing medication." 2. "I should ask the patient to change position rapidly after the medication use." 3. "I should instruct the patient to report changes in the pattern of pain to the health care provider." 4. "I should encourage the patient to administer the medication every 30 minutes sublingually if symptoms persist."

3. "I should instruct the patient to report changes in the pattern of pain to the health care provider." Short-acting nitrates such as nitroglycerin (NTG) are first-line medications for angina. The nurse has to instruct the patient on NTG to report any changes in the pattern of pain, frequency of attack, or nocturnal angina to the health care provider. The nurse must direct the patient to spray the medication on his or her tongue. The nurse should ask the patient to slowly change positions after NTG use to avoid the effects of orthostatic hypotension. The nurse should ask the patient to take NTG every five minutes for a maximum of three doses if symptoms are not resolved.

The nurse is providing postoperative care to a patient that underwent coronary artery bypass graft (CABG) surgery. The nurse should monitor the patient for what common complication? 1. Dehydration 2. Paralytic ileus 3. Atrial dysrhythmias 4. Acute respiratory distress syndrome

3. Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first three days following CABG surgery. Although dehydration, paralytic ileus, and acute respiratory distress syndrome could occur, they are not common complications. STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

The nurse reviews a patient's medical record and notes documentation of what condition that refers to arterial anastomoses or connections? 1. Atheromas 2. Angiogenesis 3. Collateral circulation 4. Coronary artery disease

3. Collateral circulation Collateral circulation occurs when arterial anastomoses or connections are formed. Coronary artery disease is a type of blood vessel disorder that is included in the general category of atherosclerosis. Atheromas are fatty deposits that are formed in coronary arteries. Angiogenesis is an inherited disposition to develop new blood vessels.

The nurse assesses a patient with papillary muscle dysfunction. Which observation supports the patient's diagnosis? 1. Crackles 2. S3 heart sound 3. Murmur at the cardiac apex 4. Deep sound noted while auscultating at the lower sternal border

3. Murmur at the cardiac apex Papillary muscle dysfunction occurs if the papillary muscles attached to the mitral valves are involved in infarction. A patient may have papillary muscle infraction if a murmur is heard upon auscultation at the cardiac apex. The presence of crackles of breath sounds and S 3 and S 4 sounds of the heart indicate heart failure. The deep sound heard at the lower left sternal border upon auscultation indicates acute pericarditis.

Which is a characteristic of a complicated lesion? 1. Formation of a fibrous plaque 2. Lipid-filled smooth muscle cells 3. Platelet aggregation and adhesion 4. Transport of lipids into arterial intima

3. Platelet aggregation and adhesion A complicated lesion is characterized by accumulation of platelets leading to thrombus formation. Formation of a fibrous plaque is the beginning of progressive changes in the endothelium of the arterial wall. It is called the fibrous plaque stage. Fatty streaks are the earliest lesions of atherosclerosis and are characterized by lipid-filled smooth muscle cells. Transport of lipids into the arterial intima occurs in the fibrous plaque stage.

The nurse is performing an assessment on a newly admitted patient who presented to the emergency department with reports of chest pain. Which assessment data would indicate that the patient has stable angina? 1. The patient developed chest pain shortly after going to bed. 2. The patient developed chest pain while sitting and reading a book. 3. The pain developed when the patient was jogging and subsided after the patient rested. 4. The pain starts approximately the same time every day without regard to activity level.

3. The pain developed when the patient was jogging and subsided after the patient rested. Pain associated with stable angina is precipitated by increased demand of myocardial muscle for oxygen that happens with exercising or other activity and subsides with rest in 5 to 15 minutes. Prinzmetal's angina (variant angina) occurs at rest. Nocturnal angina occurs when patient is supine in bed. Prinzmetal's angina (variant angina) is characterized by pain that occurs at the same time of the day. Test-Taking Tip: Because few things in life are absolute without exceptions, avoid selecting answers that include words such as always, never, all, every, and none. Answers containing these key words are rarely correct.

A patient is scheduled for drug-eluting stent (DES) placement after balloon angioplasty. The nurse recalls that the reason the DES is coated with paclitaxel is what? 1. To avoid patient noncompliance to oral drugs 2. To promote patency of the affected blood vessel 3. To reduce the risk of overgrowth of the intimal lining within the stent 4. To decrease the dose of dual antiplatelet drugs that are taken to prevent stent thrombosis

3. To reduce the risk of overgrowth of the intimal lining within the stent Stents may be coated with certain medications such as paclitaxel. These medications help check the overgrowth of new intima over the stent wall, thus preventing restenosis. Drug-eluting stents do not help in promoting drug compliance or promoting the patency of the affected blood vessel. The dose of dual antiplatelet therapy is not dependent on the type of stent used.

Loading dose of Clopidogrel

300-600mg

Which drug acts by direct inhibition of the clotting factor thrombin? 1. Heparin 2. Felodipine 3. Enoxaparin 4. Argatroban

4. Argatroban Argatroban is a direct thrombin inhibitor, which directly inhibits the clotting factor thrombin. Heparin is an anticoagulant, which acts by preventing conversion of fibrinogen to fibrin and prothrombin to thrombin. Felodipine is a calcium channel blocker, which prevents the entry of calcium into vascular smooth muscles and myocytes. Enoxaparin is a low-molecular-weight heparin, which binds to antithrombin III and enhances its effects.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food item? 1. Baked flounder 2. Angel food cake 3. Baked potato with margarine 4. Canned chicken noodle soup

4. Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content. Baked flounder, angel food cake, and baked potato with margarine are all low in sodium and low in fat and would be appropriate for this diet. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.

To reduce a patient's risk of coronary artery disease (CAD), the nurse recognizes that dietary teaching is needed when the patient's high density lipoprotein (HDL) and low-density lipoprotein (LDL) profile reveals what two abnormal results? 1. Increased HDLs; increased LDLs 2. Decreased HDLs; decreased LDLs 3. Increased HDLs; decreased LDLs 4. Decreased HDLs; increased LDLs

4. Decreased HDLs; increased LDLs The risk of CAD is associated with increased LDLs (> 160 mg/dL) and decreased HDLs (< 40 mg/dL).

Which is considered a nonmodifiable risk factor for coronary artery disease? 1. Obesity 2. Diabetes 3. Tobacco use 4. Family history of heart disease

4. Family history of heart disease Family history of heart disease is a nonmodifiable risk factor for coronary artery disease. Diabetes, obesity, and tobacco use are all considered modifiable risk factors for coronary artery disease.

A patient survived an episode of sudden cardiac death (SCD) and is recovering in the intensive care unit (ICU). The nurse anticipates which intervention to prevent a recurrence? 1. Drug therapy with beta-blocker 2. Coronary artery bypass graft (CABG) 3. Percutaneous coronary intervention (PCI) 4. Implantable cardioverter-defibrillator (ICD)

4. Implantable cardioverter-defibrillator (ICD) The most common approach to preventing a recurrence is the use of an ICD. It has been shown that an ICD improves survival compared with drug therapy alone. Drug therapy and a PCI will not prevent a recurrence of SCD. A coronary artery bypass graft is not necessary.

Which type of angina occurs in the absence of significant coronary artery disease (CAD)? 1. Silent angina 2. Unstable angina 3. Prinzmetal's angina 4. Microvascular angina

4. Microvascular angina Microvascular angina occurs in the absence of coronary atherosclerosis or vasospasm. It is mainly associated with abnormalities of coronary microcirculation. Silent ischemia mostly occurs in patients with diabetes because diabetic neuropathy affects the nerves that innervate the cardiovascular system. Unstable angina occurs due to the rupture of thickened plaque. Prinzmetal's angina often occurs at rest in response to spasms of a major coronary artery. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A patient who has received a maximum dose of nitroglycerin continues to report chest pain. What is the next medication that the nurse should administer to the patient? 1. Esmolol 2. Docusate 3. Ticagrelor 4. Morphine sulfate

4. Morphine sulfate Morphine sulfate is the drug of choice for a patient with unrelieved chest pain even after the administration of nitroglycerin. Esmolol is a beta blocker used to slow down the heart during minimally invasive direct coronary artery bypass (MIDCAB). Docusate is a stool softener that facilitates bowel movements. Ticagrelor is used in dual antiplatelet therapy on a patient with ongoing angina and negative cardiac markers.

The nurse is reviewing a plan of care for emergency treatment of a patient with chest pain. The nurse should question which item listed on the plan? 1. Give a high-dose statin. 2. Give 162 to 325 mg aspirin (chewable). 3. Start O 2 by nasal cannula to keep O 2 saturation above 93%. 4. Provide the patient with instructions related to cough and deep breathing exercises.

4. Provide the patient with instructions related to cough and deep breathing exercises. Rapid diagnosis and providing treatment to a patient with acute coronary syndrome help preserve cardiac muscle function. The initial treatment is to manage chest pain; therefore the patient needs to rest and limit activities (including breathing exercises) for 12 to 24 hours. The nurse should make sure that the oxygen saturation stays at an acceptable level by initiating supplemental oxygen. Aspirin is part of the antiplatelet therapy. Statins are lipid-lowering drugs. They block synthesis of cholesterol and increase LDL receptors in the liver.

When analyzing an ECG rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______.

60

Loading dose of Prasugrel

60 mg

Maintenance dose of Clopidogrel

75 mg qd

Maintenance of Ticagrelor

90mg BID

Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? A 45-yr-old depressed man with a high-stress job A 60-yr-old man with below normal homocysteine levels A 54-yr-old woman vegetarian with elevated high-density lipoprotein (HDL) levels A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

A 45-yr-old depressed man with a high-stress job The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

Which patient is at greatest risk for sudden cardiac death (SCD)? A 42-yr-old white woman with hypertension and dyslipidemia A 52-yr-old African American man with left ventricular failure A 62-yr-old obese man with diabetes mellitus and high cholesterol A 72-yr-old Native American woman with a family history of heart disease

A 52-yr-old African American man with left ventricular failure Patients with left ventricular dysfunction (ejection fraction <30%) and ventricular dysrhythmias after myocardial infarction are at greatest risk for SCD. Other risk factors for SCD include (1) male gender (especially African American men), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes mellitus, (5) hypercholesterolemia, (6) hypertension, and (7) cardiomyopathy.

When providing nutritional counseling for patients at risk for coronary artery disease (CAD), which foods would the nurse encourage patients to include in their diet (select all that apply.)? A. Tofu B. Walnuts C. Tuna fish D. Whole milk E. Orange juice

A B C Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? A Oxygen, nitroglycerin, aspirin, and morphine B Oxygen, furosemide (Lasix), nitroglycerin, and meperidine C Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen D Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? A Tofu B Walnuts C Tuna fish D Whole milk E Orange juice

A Tofu B Walnuts C Tuna fish Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? A White male B Hispanic male C African American male D Native American female

A White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

d

A patient was admitted to the emergency department 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). Which of the following complications of MI should the nurse anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias

The nurse has received change-of-shift report about all of these patients on the telemetry unit. Which patient should the nurse see first?

A patient whose ICD fired three times today who is scheduled for a dose of amiodarone (Cordarone)

A 52-year-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). To determine the effectiveness of this medication, the nurse should assess the patient for the A presence of chest pain. B blood in the urine or stool. C tachycardia with hypotension. D decreased level of consciousness.

A presence of chest pain. Alteplase is a fibrinolytic that is administered to patients who have had an STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

A 52-yr-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? A. Presence of chest pain B. Blood in the urine or stool C. Tachycardia with hypotension D. Decreased level of consciousness

A. Alteplase is a fibrinolytic agent that is administered to patients who have had an STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? A. A 45-yr-old depressed man with a high-stress job B. A 60-yr-old man with below normal homocysteine levels C. A 54-yr-old woman vegetarian with elevated high-density lipoprotein (HDL) levels D. A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

A. The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "A little swelling around my lips and face is okay." b. "The medication may not work as well if I take any aspirin." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."

ANS: A Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

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

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

25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. bell of the stethoscope with the patient in the left lateral position. b. diaphragm of the stethoscope with the patient in a supine position. c. bell of the stethoscope with the patient sitting and leaning forward. d. diaphragm of the stethoscope with the patient lying flat on the left side.

ANS: A Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2

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

ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of a. asthma. b. daily alcohol use. c. peptic ulcer disease. d. myocardial infarction (MI).

ANS: A Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. β-Blocker therapy is recommended after MI.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. increase the dietary intake of high-potassium foods. b. make an appointment with the dietitian for teaching. c. check the blood pressure (BP) with a home BP monitor at least once a day. d. move slowly when moving from lying to sitting to standing.

ANS: A The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

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

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

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.8 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL

ANS: A The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42. b. newly admitted patient with a BP of 150/87. c. patient with left ventricular failure who has a BP of 110/70. d. patient with a myocardial infarction who has a BP of 140/86.

ANS: A The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg

27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Sildenafil (Viagra) b. Furosemide (Lasix) c. Captopril (Capoten) d. Warfarin (Coumadin)

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

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

ANS: A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b. 52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

ANS: A The patient with chest pain may be experiencing acute myocardial infarction, and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.

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

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

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

ANS: B A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths

33. When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: B Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. Inform the patient about the reasons for a possible change in drug dosage. b. Question the patient about whether the medication is actually being taken. c. Inform the patient that multiple drugs are often needed to treat hypertension. d. Question the patient regarding any lifestyle changes made to help control BP.

ANS: B Because noncompliance with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient compliance with the prescribed therapy.

39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

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

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

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Blood potassium level of 3.0 mEq/L c. Most recent blood pressure (BP) reading of 168/94 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next? a. Find the point of maximal impulse. b. Determine the timing of the murmur. c. Compare the apical and radial pulse rates. d. Palpate the quality of the peripheral pulses.

ANS: B Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is also important in the cardiac assessment but will not provide information that is relevant to the murmur

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

ANS: B Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

ANS: B Patients who have been taking β-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking β-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

ANS: B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc

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

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? a. "Did you take any acetaminophen (Tylenol) today?" b. "Have you been consistently taking your medications?" c. "Have there been any recent stressful events in your life?" d. "Have you recently taken any antihistamine medications?"

ANS: B Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse a. presses on the skin over the tibia for 10 seconds to check for edema. b. palpates both carotid arteries simultaneously to compare pulse quality. c. documents a murmur heard along the right sternal border as a pulmonic murmur. d. places the patient in the left lateral position to check for the point of maximal impulse.

ANS: B The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

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

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

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

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? a. 102/60 mm Hg b. 128/76 mm Hg c. 139/90 mm Hg d. 136/82 mm Hg

ANS: B The goal for antihypertensive therapy for a patient with hypertension and diabetes mellitus is a BP <130/80 mm Hg. The BP of 102/60 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

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

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.

ANS: B The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

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

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

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks a beer with dinner on most nights

ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient scheduled for exercise electrocardiography about the procedure b. Placing electrodes in the correct position for a patient who is to receive ECG monitoring c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

ANS: B UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice

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

ANS: B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

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

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

ANS: C All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

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

ANS: C Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. LDL cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels

An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. Schedule the patient for regular blood pressure (BP) checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Inform the patient that ambulatory blood pressure monitoring will be needed.

ANS: C Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring are unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.

12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patient's environment for adverse stimuli that might increase BP.

ANS: C LPN/LVN education and scope of practice include the correct use of common equipment such as automatic blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs.

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

ANS: C Labetalol decreases sympathetic nervous system activity by blocking both á- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

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

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

ANS: C MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information also will be reported to the health care provider but does not impact on whether or not the patient can have an MRI

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

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

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

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which patient laboratory result is most important to communicate as soon as possible to the health care provider? a. Patient whose triglyceride level is high b. Patient who has very low homocysteine level c. Patient with increase in troponin T and troponin I level d. Patient with elevated high-sensitivity C-reactive protein level

ANS: C The elevation in troponin T and I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent blood pressure (BP) reading is 158/91 mm Hg. b. The patient's pulse has dropped from 68 to 57 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

42. After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Ongoing cardiac risk associated with history of tobacco use

ANS: C The patient has an elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index (BMI) indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.

18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

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

17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

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

37. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.

41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to a. lower heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.

ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

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

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

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.

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

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

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

The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient checks BP daily just after getting up. c. Patient drinks wine three to four times a week. d. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.

ANS: D Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.

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

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

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient complaint of feeling tired b. Pulse change from 87 to 101 beats/minute c. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg d. Newly inverted T waves on the electrocardiogram

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

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient has two cups of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

ANS: D For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

ANS: D Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Increasing physical activity will control blood pressure (BP) for most patients. b. Most patients are able to control BP through dietary changes. c. Annual BP checks are needed to monitor treatment effectiveness. d. Hypertension is usually asymptomatic until target organ damage occurs.

ANS: D Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage blood pressure, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months once stable.

36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice.

43. After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

ANS: D Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring.

ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit

During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to a. ask the patient about risk factors for atherosclerosis. b. document that the PMI is in the normal anatomic location. c. auscultate both the carotid arteries for the presence of a bruit. d. assess the patient for symptoms of left ventricular hypertrophy.

ANS: D The PMI should be felt at the intersection of the fifth intercostal space and the left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease

A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication? a. Check blood pressure (BP) in both arms before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

ANS: D The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the medication, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

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

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

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

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

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

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

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse? a. The PR interval is 0.21 seconds. b. The QRS duration is 0.13 seconds. c. There is a right bundle-branch block. d. The heart rate (HR) is 42 beats/minute.

ANS: D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches

38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

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

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart.

ANS: D Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next? a. Document this finding in the patient's record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees.

ANS: D When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated

Antiplatelet (GP IIb/IIIa Inhibitor)

Abciximab (Reopro)

IV Antiplatelets

Abciximab, Eptifibatide, Tirofiban, Cangrelor

Cholestyramine SE

Abdominal discomfort Constipation, Nausea Irritation of tongue

alteplase (tPA)

Activase - fibrin-specific fibrinolytic - Dosing: 1. 15 mg IV bolus 2. 0.75 mg/kg IV over 30 min (*max 50 mg*) 3. 0.5 mg/kg IV over 1 hour (*100 mg total*)

The patient is being dismissed from the hospital after acute coronary syndrome and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? Therapeutic lifestyle changes should become lifelong habits. Physical activity is always started in the hospital and continued at home. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. Activity level is gradually increased under cardiac rehabilitation team supervision and with electrocardiographic (ECG) monitoring.

Activity level is gradually increased under cardiac rehabilitation team supervision and with electrocardiographic (ECG) monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or myocardial infarction, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

Ezetimibe Mechanisms

Acts on cells of small intestine to inhibit dietary cholesterol absorption Inhibits reabsorption of cholesterol from bile Reduce total LDL cholesterol, and apolipoprotein B for patients with Hypo-cholesteremia

Other Antidysrhythmics

Adenosine Digoxin Atropine

Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN?

Administration of the ordered metoprolol (Lopressor) and aspirin

b

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient states, A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to five tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

spironolactone

Aldactone - aldosterone antagonist (non-selective) - initial dose: 12.5 mg PO daily - target dose: 25-50 mg PO daily - AE: *gynecomastia*

A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate?

Allow the student to participate on the swim team.

A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan?

Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI.

Fibrinolytic

Alteplase

Antiplatelets Asprin (ASA low dose) Clopidogrel (Plavix)

Anti-platelets: Work to prevent platelet adhesion at the site of blood vessel injury, which actually occurs before the clotting cascade. Aspirin ( Clopidogrel (ADP inhibitor)

fondaparinux

Arixtra - *CrCl < 30 mL/min: CI* - can be used if Hx of HIT

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply.)? Flushing Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds

Ashen skin -During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds. Diaphoresis -During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds. Nausea and vomiting -During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds. S3 or S4 heart sounds -During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

Antiplatelet options

Aspirin and Clopidogrel (Plavix)

Beta-Adrenergic Blockers

Atenolol Metoprolol Propranolol

HMG-CoA Reductase Inhibitors (Statins)

Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? Dehydration Paralytic ileus Atrial dysrhythmias Acute respiratory distress syndrome

Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

While admitting a patient with an AMI, which action should the nurse carry out first?

Attach the cardiac monitor.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A "I will replace my nitroglycerin supply every 6 months." B "I can take up to five tablets every 3 minutes for relief of my chest pain." C "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

Which patient is at greatest risk for sudden cardiac death? A A 42-year-old white woman with hypertension and dyslipidemia B A 52-year-old African American man with left ventricular failure C A 62-year-old obese man with diabetes mellitus and high cholesterol D A 72-year-old Native American woman with a family history of heart disease

B A 52-year-old African American man with left ventricular failure Patients with left ventricular dysfunction (ejection fraction < 30%) and ventricular dysrhythmias after MI are at greatest risk for sudden cardiac death (SCD). Other risk factors for SCD include (1) male gender (especially African American men), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes mellitus, (5) hypercholesterolemia, (6) hypertension, and (7) cardiomyopathy.

Which individuals would the nurse identify as having the highest risk for CAD? A A 45-year-old depressed male with a high-stress job B A 60-year-old male with below normal homocysteine levels C A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels D A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

B A 60-year-old male with below normal homocysteine levels The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? A Unstable angina B Acute coronary syndrome (ACS) C ST-segment-elevation myocardial infarction (STEMI) D Non-ST-segment-elevation myocardial infarction (NSTEMI)

B Acute coronary syndrome (ACS) The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A Flushing B Ashen skin C Diaphoresis D Nausea and vomiting E S3 or S4 heart sounds

B Ashen skin C Diaphoresis D Nausea and vomiting E S3 or S4 heart sounds During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply.)? A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

B C D E During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? A Delegated to the primary care provider B Discussed along with other physical activities C Avoided because it is embarrassing to the patient D Accomplished by providing the patient with written material

B Discussed along with other physical activities Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

The nurse prepares a discharge teaching plan for a 44-year-old male patient who has recently been diagnosed with coronary artery disease. Which risk factor should the nurse plan to focus on during the teaching session? A Type A personality B Elevated serum lipids C Family cardiac history D Hyperhomocysteinemia

B Elevated serum lipids Dyslipidemia is one of the four major modifiable risk factors for coronary artery disease (CAD). The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? A Niacin (Nicobid) B Ezetimibe (Zetia) C Gemfibrozil (Lopid) D Atorvastatin (Lipitor) E Cholestyramine (Questran)

B Ezetimibe (Zetia) D Atorvastatin (Lipitor) Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? A Sinus tachycardia B Pathologic Q wave C Fibrillatory P waves D Prolonged PR interval

B Pathologic Q wave The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is ______________

B-type natriuretic peptide (BNP).

The nurse is providing teaching to a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? A. Delegated to the primary care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

B. Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

The nurse prepares a discharge teaching plan for a 44-yr-old male patient who has recently been diagnosed with coronary artery disease (CAD). Which risk factor should the nurse plan to focus on during the teaching session? A. Type A personality B. Elevated serum lipids C. Family cardiac history D. Hyperhomocysteinemia

B. Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

Which patient is at greatest risk for sudden cardiac death (SCD)? A. A 42-yr-old white woman with hypertension and dyslipidemia B. A 52-yr-old African American man with left ventricular failure C. A 62-yr-old obese man with diabetes mellitus and high cholesterol D. A 72-yr-old Native American woman with a family history of heart disease

B. Patients with left ventricular dysfunction (ejection fraction < 30%) and ventricular dysrhythmias after MI are at greatest risk for sudden cardiac death (SCD). Other risk factors for SCD include (1) male gender (especially African American men), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes mellitus, (5) hypercholesterolemia, (6) hypertension, and (7) cardiomyopathy.

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? A. Sinus tachycardia B. Pathologic Q wave C. Fibrillatory P waves D. Prolonged PR interval

B. The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

The nurse is providing teaching to a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? A. Delegated to the primary care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

B. Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to five tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B. The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

Drugs that affect afterload

Beta-Adrenergic Blockers Alpha 1 Adrenergic Blockers Alpha/Beta Blockers

ticagrelor

Billinta - P2Y12 Inhibitor - All NSTEMI pts - SNTEMI Medical Management Dosing 1. LD: 180 mg 2. MD: *90 mg BID* - duration: at least 12 months - Indication: STEMI pts *undergoing PCI or medical management* - Black Box: *significant/fatal bleeding*

Anticoagulant (Direct thrombin inhibitor)

Bivalirudin (Angiomax)

Direct Thrombin Inhibitor

Bivalrudin

Action of Statins

Block cholesterol synthesis DECREASE total cholesterol, LDL, VLDL, triglycerides. INCREASE HDL

In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? A "What precipitated the pain?" B "Has the pain changed this time?" C "In what areas did you feel this pain?" D "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

C "In what areas did you feel this pain?" Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply.)? A. Niacin B. Cholestyramine C. Ezetimibe (Zetia) D. Gemfibrozil (Lopid) E. Atorvastatin (Lipitor)

C D E Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? A Palpate the insertion site for induration. B Assess peripheral pulses in the right leg. C Inspect the patient's right side and back. D Compare the color of the left and right legs.

C Inspect the patient's right side and back. The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

A 74-year-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? A Administer morphine sulfate IV. B Auscultate heart and lung sounds. C Obtain a 12-lead electrocardiogram (ECG). D Assess for coronary artery disease risk factors.

C Obtain a 12-lead electrocardiogram (ECG). If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? A. Administer morphine sulfate IV. B. Auscultate heart and lung sounds. C. Obtain a 12-lead electrocardiogram (ECG). Correct D. Assess for coronary artery disease risk factors.

C. If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

C. Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? A. Palpate the insertion site for induration. B. Assess peripheral pulses in the right leg. C. Inspect the patient's right side and back. D. Compare the color of the left and right legs.

C. The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? A. "What precipitated the pain?" B. "Has the pain changed this time?" C. "In what areas did you feel this pain?" D. "What is your pain level on a 0 to 10 scale?"

C. Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

C. Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

Antiplatelet (P2Y12 Inhibitor)

Cangrelor (Kengreal)

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food? Baked flounder Angel food cake Baked potato with margarine Canned chicken noodle soup

Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A patient admitted to the emergency department 24 hours ago with complaints of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? Unstable angina Cardiac tamponade Sudden cardiac death Cardiac dysrhythmias

Cardiac dysrhythmias Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A patient returns after cardiac catheterization. Which nursing care would the registered nurse delegate to the licensed practical nurse? Monitor the electrocardiogram for dysrhythmias Check for bleeding at the catheter insertion site Prepare discharge teaching related to complications Take vital signs and report abnormal values

Check for bleeding at the catheter insertion site The licensed practical nurse can check for bleeding at the puncture sites. If bleeding is identified, it should be reported to the registered nurse. Vital signs should be delegated to the unlicensed assistive personnel. Preparation of discharge teaching and monitoring for dysrhythmias such as S-T elevation would be registered nurse scope of practice.

Drugs used to treat dysrhythmias

Class 1- Sodium Channel Blockers Class 2- Beta-Adrenergic Blockers Class 3- Potassium Channel Blockers Class 4- Calcium Channel Blockers Other Antidysrhythmics

What you should know about Nitroglycerin (NTG)

Comes in sublingual tab, spray, or cream Store tabs in brown bottle Teach pt to use prophylactically (can be taken to prevent Angina)

The nurse instructs a 68-year-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement? A "Omega-3 fatty acids are helpful in reducing triglyceride levels." B "I should check with my physician before I start taking any herbal products." C "Herbal products do not go through as extensive testing as prescription drugs do." D "I will take garlic instead of my prescription medication to reduce my cholesterol."

D "I will take garlic instead of my prescription medication to reduce my cholesterol." Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? A Therapeutic lifestyle changes should become lifelong habits. B Physical activity is always started in the hospital and continued at home. C Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. D Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring.

D Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or MI, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A Chronic stable angina B Left-sided heart failure C Coronary artery disease D Acute myocardial infarction

D Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? A Baked flounder B Angel food cake C Baked potato with margarine D Canned chicken noodle soup

D Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? A Unstable angina B Cardiac tamponade C Sudden cardiac death D Cardiac dysrhythmias

D Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? A External pacemaker B An electrophysiologic study (EPS) C Medications to prevent dysrhythmias D Implantable cardioverter-defibrillator (ICD)

D Implantable cardioverter-defibrillator (ICD) An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? A Exercise almost every day. B Avoid saturated fat intake. C Limit calories to daily limit. D Keep Hgb A1C less than 7%.

D Keep Hgb A1C less than 7%. If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? A Consume a diet low in fats. B Reduce total caloric intake. C Increase intake of olive oil. D The lipid levels are normal.

D The lipid levels are normal. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

A patient experienced sudden cardiac death (SCD) and survived. Which preventive treatment should the nurse expect to be implemented? A. External pacemaker B. An electrophysiologic study (EPS) C. Medications to prevent dysrhythmias D. Implantable cardioverter-defibrillator (ICD)

D. An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What should the nurse include in patient teaching? A. Consume a diet low in fats. B. Reduce total caloric intake. C. Increase intake of olive oil. D. The lipid levels are normal.

D. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

The patient is being dismissed from the hospital after acute coronary syndrome and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? A. Therapeutic lifestyle changes should become lifelong habits. B. Physical activity is always started in the hospital and continued at home. C. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. D. Activity level is gradually increased under cardiac rehabilitation team supervision and with electrocardiographic (ECG) monitoring.

D. In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or myocardial infarction, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease D. Acute myocardial infarction

D. PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food? A. Baked flounder B. Angel food cake C. Baked potato with margarine D. Canned chicken noodle soup

D. Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A patient admitted to the emergency department 24 hours ago with complaints of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias

D. Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

The nurse instructs a 68-yr-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement? A. "Omega-3 fatty acids are helpful in reducing triglyceride levels." B. "I should check with my physician before I start taking any herbal products." C. "Herbal products do not go through as extensive testing as prescription drugs do." D. "I will take garlic instead of my prescription medication to reduce my cholesterol."

D. Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

how is ticagrelor different than clopidogrel and prasugrel?

binds P2Y12 reversibly

In the hospital, why do we use Morphine?

Decreases Preload and Afterload

Nitro Stable Angina

Decreases cardiac oxygen demand by decreasing venous return to heart and decreasing wall tension

Beta adrenergic blockers

Decreases future MI's and mortality by blocking SNS

Aspirin

Decreases platelet aggregation

Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a ____________

pericardial friction rub.

when prasugrel contraindicated

previous stroke patients > 75

The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for _______________

relief of chest discomfort.

A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care?

sildenafil (Viagra)

Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is ___________________

situational low self-esteem related to perceived role changes.

The nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should _______________

start basic cardiopulmonary resuscitation (CPR).

17. A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response. The nurse teaches the patient that the pacemaker will ____________

stimulate a heart beat if the patient's own heart rate drops too low.

A patient experiences dizziness and shortness of breath for several days. During cardiac monitoring in the ED, the nurse obtains the following ECG tracing. The nurse interprets this cardiac rhythm as _______________

third-degree AV block.

When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will ______________

use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as _______________

ventricular tachycardia.

A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to ________________________

visualize any coronary artery blockages and dilate any obstructed arteries.

For a patient who has been admitted the previous day to the coronary care unit with an AMI, the nurse will anticipate teaching the patient about _______________

when patient cardiac rehabilitation will begin.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply.)? Niacin Cholestyramine Ezetimibe (Zetia) Gemfibrozil (Lopid) Atorvastatin (Lipitor)

Ezetimibe (Zetia) -Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use. Gemfibrozil (Lopid) -Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use. Atorvastatin (Lipitor) -Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

Which factor should be considered when caring for a woman with suspected coronary artery disease? Fatigue may be the first symptom. Classic signs and symptoms are expected. Increased risk is present before menopause. Women are more likely to develop collateral circulation.

Fatigue may be the first symptom. Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. Men are more likely to develop collateral circulation.

Which factor should be considered when caring for a woman with suspected coronary artery disease? A. Fatigue may be the first symptom. B. Classic signs and symptoms are expected. D. Increased risk is present before menopause. E. Women are more likely to develop collateral circulation.

Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. Men are more likely to develop collateral circulation.

Epinephrine

First medication given in cardia arrest

Factor Xa/Anti-Xa Inhibitor

Fondaparinux

Anticoagulant (Factor Xa)

Fondaparinux (Arixtra)

Loop Diuretics

Furosemide Bumetanide

Side effects of Bile Acid Derivatives

GI constipation, N/V *take with meal, may need stool softener.

Side effects of Fibric Acid Derivatives

GI irritability

Fibrates

Gembibrozil Fenofibrate

A patient with hyperlipidemia has a new order for the bile-acid sequestrant medication colesevelam (Welchol). Which nursing action is appropriate when giving the medication?

Give the patient's other medications 2 hours after the Welchol.

Amiodarone

Given for atrial and ventricular dysrhythmias

Normal Saline

Given for fluid resuscitation in shock

Atropine

Given for symptomatic bradycardia

Coumadin

Given w/ atrial flutter or fibrillation to prevent clot formation

Drugs to treat coronary artery disease (CAD)—> Antilipidemics

HMG-CoA Reductase Inhibitors (statins) Bile-Acid Sequestrants Nicotinic Acid Fibrates Others (Antilipidemics)

Nitro SE

Headache Orthostatic hypotension (relaxation of VSM causes blood to pool in veins) Decreased venous return to the heart causing BP to fall. Reflex tachycardia

Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased?

Heart rate increases from 66 to 90 beats/min.

ASA SE

Hemorrhagic Stroke Increased risk of GI bleeding

A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin?

Heparin will prevent the development of clots in the coronary arteries.

A patient's sinus rhythm rate is 62. The PR interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 12:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take?

Hold the ordered metoprolol (Lopressor) and call the health care provider.

Direct-Acting Vasodilators

Hydralazine Sodium-Nitroprusside

Thiazide Diuretics

Hydrochlorothiazide (HTZ)

A patient experienced sudden cardiac death (SCD) and survived. Which preventive treatment should the nurse expect to be implemented? External pacemaker An electrophysiologic study (EPS) Medications to prevent dysrhythmias Implantable cardioverter-defibrillator (ICD)

Implantable cardioverter-defibrillator (ICD) An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

Action of Bile Acid Sequestrates (Cholestryamine, Colestipol)

Increases the conversion of cholesterol to bile acids - excreted in feces. DECREASE LDL

Enoxaparin (Lovenox)

Indication: Prevention and treatment of thromboembolic and ischemic processes in unstable angina and postoperative and post-MI situations. Patients at risk for clots are given DVT prophylaxis while in the hospital and after major surgery. LMWHs, especially enoxaparin, are also routinely used as anticoagulant bridge therapy in situations in which a patient must stop warfarin for surgery or other invasive medical procedures. The term bridge therapy refers to the fact that enoxaparin acts as a bridge to provide anticoagulation while the patient must be off of his or her warfarin therapy. Mechanism of action: LMWH is a smaller fragment of heparing and have a greater affinity for factor Xa. Contraindications: Indwelling epidural catheter (but can be given 2 hours after indwelling epidural catheter is removed) Adverse effects: Localized or systemic bleeding THAB Administering: Prefilled syringes, keep the air bubble in it & given SubQ every 12 hours for prophylaxis.

Heparin

Indication: Thrombosis/embolism, coagulopathies, PR prophylaxis, clotting prevention Mechanism of Action: Binds to antithrombin III--> The overall effect of heparin is that it turns off the coagulation pathway and prevents clots from forming. Contraindications: -- Adverse Effects: Thrombocytopenia Hematoma Anemia Bleeding Heparin-Induced Thrombocytopenia (HIT)--> The greatest risk to the pt. with HIT is the paradoxical occurrence of thrombosis. Administering: Heparin is commonly used for DVT prophylaxis in a dose of 5000 units two or three times a day given subcutaneously, and it does not need to be monitored when used for prophylaxis. When heparin is used therapeutically (for treatment), it is given by continuous IV infusion. Toxicity and management: In the event of bleeding, the drug is to be stopped immediately. In the case of heparin, stopping the drug alone may be enough to reverse the toxic effects because of the drug's short half-life (1-2 hrs.) Antidote: Protamine, completely reverses the effects of heparin in about 5 minutes. 1mg:1mg heparin to protamine

Action of Cholesterol Absorption Inhibitors (Ezetimibe)

Inhibits the absorption of cholesterol in small intestines.

MONAA

Initial STEMI Therapy - Morphine (+/-) - Oxygen (+/-) - Nitroglycerin (NTG) - Aspirin - Anticoagulant (UFH/LMWH)

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? Palpate the insertion site for induration. Assess peripheral pulses in the right leg. Inspect the patient's right side and back. Compare the color of the left and right legs.

Inspect the patient's right side and back. The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

eplerenone

Inspra - aldosterone antagonist (selective) - initial dose: 25 mg PO daily - target dose: 50 mg PO daily

eptifibatide

Integrilin - Glycoprotein IIb/IIIa Inhibitor - Duration: 18-24 hours post-PCI - *Dose adjust CrCl < 50 mL/min* - *avoid in HD pts*

Niacin SE

Intense flushing (face, neck, ears) , GI upset (n/v, gastric upset, diarrhea) Liver injury Elevate blood levels of uric acid Hyperglycemia Gouty arthritits

Action of Niacin/Nicotinic Acid

Interferes with the synthesis of LDL DECREASE LDL and triglycerides. INCREASE HDL

Clopidogrel

Irreversibly inhibiting ATP from binding to receptors on the platelet surface, thereby inhibiting platelet aggregation

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? Exercise almost every day. Avoid saturated fat intake. Limit calories to daily limit. Keep Hgb A1C (A1C) less than 7%.

Keep Hgb A1C (A1C) less than 7%. If the Hgb A1C (A1C) is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

Calcium Channel Blockers

Lessen the contractility in the heart

Drugs that affect preload

Loop diuretics Thiazide diuretics Potassium-sparing diuretics Osmotic diuretics

metoprolol tartrate

Lopressor - beta-blocker - *MD: 25-100 mg PO BID* - most common IV beta-blocker

Beta Blockers

Lower HR

Cholestyramine

Lowers LDL Cholesterol by binding to bile acids in the GI tract, forming an insoluble complex.

A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring?

MCL1

Side effects of Cholesterol Absorption Inhibitors

MINIMAL. *take with or without meal. Watch when taking with Statins.

Osmotic Diuretic

Mannitol

Stool softener

Minimizes development of bradycardia from vagal stimulation

anticoagulation therapy prevents thrombus formation after STEMI/NSTEMI

NSTEMI and unstable angina

Synthetic B-Naturetic Peptide (BNP)

Nesiritide

Nicotinic Acid

Niacin

Organic Nitrates

Nitroglycerin Isosorbide

Nitro Tolerance

Nitroglycerin-induced vasodilation can develop rapidly by Depletion of sulfhydryl Reversible oxidative injury to enzyme Use in lowest effective doses and long acting 8 hours drug free daily Use short acting nitrate in between doses Reversed by withholding meds for a short time

A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse?

No change in the patient's chest pain

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? Administer morphine sulfate IV. Auscultate heart and lung sounds. Obtain a 12-lead electrocardiogram (ECG). Assess for coronary artery disease risk factors.

Obtain a 12-lead electrocardiogram (ECG). If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The patient's blood pressure (BP) is 102/68. The nurse places the patient on a cardiac monitor and obtains the following ECG tracing. Which action should the nurse take next?

Obtain further information about possible causes for the heart rate.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? Oxygen, nitroglycerin, aspirin, and morphine Aspirin, nitroprusside, dopamine, and oxygen Oxygen, furosemide (Lasix), nitroglycerin, and meperidine Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? Sinus tachycardia Pathologic Q wave Fibrillatory P waves Prolonged PR interval

Pathologic Q wave The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

Dobutamine

Positive inotropic, negative chronotropic drug used for cardiogenic shock

c

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which of the following common complications? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

Antiplatelet (P2Y12 Inhibitor)

Prasugrel (Effient)

A 52-yr-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? Presence of chest pain Blood in the urine or stool Tachycardia with hypotension Decreased level of consciousness

Presence of chest pain Alteplase is a fibrinolytic agent that is administered to patients who have had an STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

Anti-platelet

Prevent platelet aggregation; because of risk for clots

Anticoagulant

Prevent thrombus formation; because of risk for clots

A 21-year-old college student arrives at the student health center at the end of the quarter complaining, "My heart is skipping beats." The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first?

Question the patient about current stress level and coffee use.

Lidocaine

Rarely given for ventricular dysrhythmias due to toxicity

IV Nitroglycerine (Tridil)

Relieves chest pain by decreasing O2 demands and increasing O2 supply

abciximab

Reopro - Glycoprotein IIb/IIIa Inhibitor - *preferred* in class - Duration: 12 hours post-PCI

reteplase (rPA)

Retavase - fibrin-specific fibrinolytic

Fibrinolytic

Reteplase

Thrombolytics

Reteplase

Side effects of statins

Rhabdomyolysis (muscle aches), want to monitor liver enzymes. Red yeast rice is a natural source of statins.

Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?

ST-segment elevation

Side effects of Niacin

Severe flushing, redness, itching. *Take ASA 30 min before to avoid.

Potassium-sparing Diuretics

Spironolactone

Most commonly used lipid lowering med

Statins "should reduce LDL # by 50%"

Examples of Lipid lowering meds

Statins, Niacin, Fibric Acid Derivatives, Bile acid sequestrates, and Cholesterol absorption inhibitors.

Levophed

Stimulates alpha receptors to promote vasoconstriction (check peripheral pulses)

tenecteplase (TNK-tPA)

TNKase - fibrin-specific fibrinolytic

Fibrinolytic

Tenecteplase

atenolol

Tenormin - PO beta-blocker

a

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which of the following ethnic groups would the nurse select as the highest priority for this intervention? A. White male B. Hispanic male C. African American male D. Native American female

A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What should the nurse include in patient teaching? Consume a diet low in fats. Reduce total caloric intake. Increase intake of olive oil. The lipid levels are normal.

The lipid levels are normal. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

b

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which of the following ECG changes is most indicative of prolonged or complete coronary occlusion? A. Sinus tachycardia B. Pathologic Q wave C. Fibrillatory P waves D. Prolonged PR interval

b

The nurse is providing teaching to a patient recovering from an MI. Discussion regarding resumption of sexual activity should be A. Delegated to the primary care provider. B. Discussed along with other physical activities. C. Avoided because it is embarrassing to the patient. D. Accomplished by providing the patient with written material.

b, c, d, e

The nurse would assess a patient with complaints of chest pain for which of the following clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which information obtained by the nurse is most relevant?

The patient's 29-year-old brother has had a sudden cardiac arrest.

Activase (alteplase)

Thrombolytic agent given to dissolve clots

Antiplatelet (P2Y12 Inhibitor)

Ticagrelor (Brilinta)

ticlopidine

Ticlid - P2Y12 Inhibitor - AE: neutropenia - not used much

Antiplatelet (GP IIb/IIIa Inhibitor)

Tirofiban (Aggrastat)

When providing nutritional counseling for patients at risk for coronary artery disease (CAD), which foods would the nurse encourage patients to include in their diet (select all that apply.)? Tofu Walnuts Tuna fish Whole milk Orange juice

Tofu -Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly. Walnuts -Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly. Tuna fish -Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

metoprolol succinate

Toprol XL - PO beta-blocker

Calcium Channel blocker

Treats atrial dysrhythmias but hypocalcemia and bradycardia can occur

A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI?

Troponin levels

Anticoagulants

Unfractionated Heparin LMWH Factor Xa Inhibitors Direct Thrombin Inhibitors

Nitro Mechanisms

Uptake of nitrate by VSM. Converted to active form (Nitric oxide) Enzyme is activated that catalyzes the formation of cyclic GMP which leads to dephosphorylation of light-chain myosin in VSM. Myosin is unable to interact with actin, so VSM relax.

d

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which of the following food choices? A. Baked flounder B. Angel food cake C. Baked potato with margarine D. Canned chicken noodle soup

a

When planning emergent care for a patient with a suspected MI, the nurse will anticipate administration of A. Oxygen, nitroglycerin, aspirin, and morphine. B. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine. C. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen. D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin).

a, b, c

When providing nutritional counseling for patients at risk for CAD, which of the following foods would the nurse encourage patients to include in their diet (select all that apply)? A. Tofu B. Walnuts C. Tuna fish D. Whole milk E. Orange juice

During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences _______________

a decrease in level of consciousness.

Which individuals would the nurse identify as having the highest risk for CAD? a) A 45-year-old depressed male with a high-stress job b) A 60-year-old male with below normal homocysteine levels c) A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels d) A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

a) A 45-year-old depressed male with a high-stress job The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? a) Oxygen, nitroglycerin, aspirin, and morphine b) Oxygen, furosemide (Lasix), nitroglycerin, and meperidine c) Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen d) Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

a) Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? a) White male b) Hispanic male c) African American male d) Native American female

a) White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? a) Tofu b) Walnuts c) Tuna fish d) Whole milk e) Orange juice

a, b, & c Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

A patient is admitted to the ICU with a diagnosis of unstable angina. Which medication(s) would the nurse expect the patient to receive (select all that apply)? a. ACE Inhibitor b. Antiplatelet Therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

a, b, & e

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says: a. "I would like to add weight lifting to my exercise program." b. "I can only keep my blood pressure normal with medication." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

a. "I would like to add weight lifting to my exercise program."

Which statement reflects correct cardiac physical assessment technique? a. Auscultate the aortic valve in the second intercostal space at the right sternal border. b. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. c. Palpate the apical pulse over the third intercostal space in the midclavicular line. d. Assess for carotid bruit by auscultating over the anterior neck.

a. Auscultate the aortic valve in the second intercostal space at the right sternal border. The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? a. C-reactive protein of 1 mg/dL b. Homocysteine level of 13 mmol/L c. Creatine kinase (CK) of 125 mg/dL d. Troponin of 5.2 ng/mL

a. C-reactive protein of 1 mg/dL b. Homocysteine level of 13 mmol/L c. Creatine kinase (CK) of 125 mg/dL d. Troponin of 5.2 ng/mL The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? a. Fatigue b. Swelling of one leg c. Slow heart rate d. Brown discoloration of lower extremities

a. Fatigue Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

Which client has the highest risk for cardiovascular disease? a. Man who smokes and whose father died at 49 of myocardial infarction (MI) b. Woman with abdominal obesity who exercises three times per week c. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL d. Man who is sedentary and reports four episodes of strep throat

a. Man who smokes and whose father died at 49 of myocardial infarction (MI) Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) a. Troponin 3.2 ng/mL b. Myoglobin 234 mcg/L c. C-reactive protein 13 mg/dL d. Triglycerides 400 mg/dL e. Lipoprotein-a 18 mg/dL

a. Troponin 3.2 ng/mL b. Myoglobin 234 mcg/L Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient _______________

about the purpose of outpatient Holter monitoring.

beta blockers should be avoided in acute/chronic heart failure

acute (A-BEAM are used for chronic heart failure)

A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of ___________________

acute pain related to myocardial ischemia.

The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50-second episode of ventricular tachycardia before a sinus rhythm and a heart rate of 98 were re-established. The most appropriate initial action by the nurse is to ________________

administer IV antidysrhythmic drugs per protocol.

A patient with supraventricular tachycardia (SVT) is hemodynamically stable and requires cardioversion. The nurse will plan to _______________

administer a sedative before the procedure is begun.

Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about _______________

angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that further treatment of the patient will require ____________

anticoagulant therapy with warfarin (Coumadin).

During change-of-shift report, the nurse learns that a patient with a large myocardial infarction has been having frequent PVCs. When monitoring the patient for the effects of PVCs, the nurse will check the patient's _____________

apical radial heart rate.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? a) Niacin (Nicobid) b) Ezetimibe (Zetia) c) Gemfibrozil (Lopid) d) Atorvastatin (Lipitor) e) Cholestyramine (Questran)

b & d Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a) "I will replace my nitroglycerin supply every 6 months." b) "I can take up to five tablets every 3 minutes for relief of my chest pain." c) "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." d) "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

b) "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? a) Unstable angina b) Acute coronary syndrome (ACS) c) ST-segment-elevation myocardial infarction (STEMI) d) Non-ST-segment-elevation myocardial infarction (NSTEMI)

b) Acute coronary syndrome (ACS) The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? a) Delegated to the primary care provider b) Discussed along with other physical activities c) Avoided because it is embarrassing to the patient d) Accomplished by providing the patient with written material

b) Discussed along with other physical activities Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? a) Sinus tachycardia b) Pathologic Q wave c) Fibrillatory P waves d) Prolonged PR interval

b) Pathologic Q wave The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include (select all that apply): a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, especially low-density lipoproteins c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

b, c, & d

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? a) Flushing b) Ashen skin c) Diaphoresis d) Nausea and vomiting e) S3 or S4 heart sounds

b, c, d, & e During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? a. "I don't know how I am going to change my lifestyle." b. "I don't need to change. It hasn't killed me yet." c. "I don't think it is as bad as the doctors say." d. "I will have to change my diet and exercise more."

b. "I don't need to change. It hasn't killed me yet." A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? a. "Monitor the pulses in your feet when you get home." b. "Keep your affected leg straight for 2 to 6 hours." c. "Do not take your blood pressure medications on the day of the procedure." d. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

b. "Keep your affected leg straight for 2 to 6 hours." The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? a. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index c. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging d. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

Which statement about diagnostic cardiovascular testing is correct? a. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. c. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. d. The left side of the heart is catheterized first and may be the only side examined.

b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) a. Squeezing, vise-like chest pain b. Chest pain relieved by sitting upright c. Chest and abdominal pain relieved by antacids d. Sudden-onset chest pain relieved by anti-inflammatory agents e. Pain in the chest described as sharp or stabbing

b. Chest pain relieved by sitting upright d. Sudden-onset chest pain relieved by anti-inflammatory agents e. Pain in the chest described as sharp or stabbing The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? a. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted b. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes c. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain d. Client who has many questions about the electrophysiology studies (EPS) scheduled for today

b. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

a. Man who smokes and whose father died at 49 of myocardial infarction (MI) b. Woman with abdominal obesity who exercises three times per week c. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL d. Man who is sedentary and reports four episodes of strep throat a. Client with abdominal pain and belching b. Client with pressure in the mid-abdomen and profound diaphoresis c. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows d. Client with claudication and fatigue

b. Client with pressure in the mid-abdomen and profound diaphoresis Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? a. No intervention is needed; this is a normal reading. b. Collaborate with the health care provider to administer a positive inotropic agent. c. Administer a STAT dose of metoprolol (Lopressor). d. Ask the client to perform the Valsalva maneuver.

b. Collaborate with the health care provider to administer a positive inotropic agent. A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) a. Consuming a diet rich in fiber b. Elevated C-reactive protein levels c. Low blood pressure d. Elevated high-density lipoprotein (HDL) cholesterol level e. Smoking

b. Elevated C-reactive protein levels e. Smoking Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? a. Right atrial pressure is 4 mm Hg. b. Mean arterial pressure (MAP) is 58 mm Hg. c. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. d. PO2 is reported as 78 mm Hg.

b. Mean arterial pressure (MAP) is 58 mm Hg. Correct To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

The nurse is caring for a patient who is 2 days post-MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action would be a priority? a. Notify the physician STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow oxygen by face mask and auscultate breath sounds. d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes.

b. Obtain vital signs and auscultate for a pericardial friction rub.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? a. Calcium 8.5 mEq/L b. Potassium 3.0 mEq/L c. Magnesium 2.1 mEq/L d. International normalized ratio (INR) of 1.0

b. Potassium 3.0 mEq/L Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? a. The client has had intermittent substernal chest pain for 6 months. b. The client develops wheezes and dyspnea after eating crab or lobster. c. The client reports that a previous arteriogram was negative for coronary artery disease. d. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

b. The client develops wheezes and dyspnea after eating crab or lobster. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? a. NPO status will cause the client to be thirsty. b. The dye causes an osmotic diuresis. c. The dye contains a heavy sodium load. d. The pedal pulses will be more easily palpable.

b. The dye causes an osmotic diuresis. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia: a. will always progress to myocardial infarction b. will be relieved by rest, nitroglycerin, or both c. indicates that irreversible myocardial damage is occurring d. is frequently associated with vomiting and extreme fatigue

b. will be relieved by rest, nitroglycerin, or both

clopidogrel toxicity

bleeding, dyspepsia, rashes

In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? a) "What precipitated the pain?" b) "Has the pain changed this time?" c) "In what areas did you feel this pain?" d) "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

c) "In what areas did you feel this pain?" Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? a) Dehydration b) Paralytic ileus c) Atrial dysrhythmias d) Acute respiratory distress syndrome

c) Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? a) Palpate the insertion site for induration. b) Assess peripheral pulses in the right leg. c) Inspect the patient's right side and back. d) Compare the color of the left and right legs.

c) Inspect the patient's right side and back. The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks b. Plan a diet program that aims for a 1 to 2 pound weight loss per week c. Begin an exercise program that aims for at least five 30-minute sessions per week d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity

c. Begin an exercise program that aims for at least five 30-minute sessions per week

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? a. Dietary consult b. Sodium restriction Incorrect c. Daily weight monitoring d. Restricted activity

c. Daily weight monitoring A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? a. Maintains NPO (nothing by mouth) until this resolves b. Calls in another nurse for a second opinion c. Performs a complete neurologic assessment and notifies the health care provider d, Explains to the client and family that this is expected after sedation

c. Performs a complete neurologic assessment and notifies the health care provider Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? a. White blood cell count b. Low-density lipoproteins c. Serum troponin I level d. C-reactive protein

c. Serum troponin I level Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? a. This blood pressure is good because it is a normal reading. b. This blood pressure indicates that the client has hypertension or high blood pressure. c. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. d. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

c. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

The most common finding in individuals at risk for sudden cardiac death is: a. aortic valve disease b. mitral valve disease c. left ventricular dysfunction d. atherosclerotic heart disease

c. left ventricular dysfunction

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? a) Therapeutic lifestyle changes should become lifelong habits. b) Physical activity is always started in the hospital and continued at home. c) Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. d) Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring.

d) Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or MI, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? a) Chronic stable angina b) Left-sided heart failure c) Coronary artery disease d) Acute myocardial infarction

d) Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? a) Baked flounder b) Angel food cake c) Baked potato with margarine d) Canned chicken noodle soup

d) Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? a) Unstable angina b) Cardiac tamponade c) Sudden cardiac death d) Cardiac dysrhythmias

d) Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? a) External pacemaker b) An electrophysiologic study (EPS) c) Medications to prevent dysrhythmias d) Implantable cardioverter-defibrillator (ICD)

d) Implantable cardioverter-defibrillator (ICD) An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? a) Exercise almost every day. b) Avoid saturated fat intake. c) Limit calories to daily limit. d) Keep Hgb A1C less than 7%.

d) Keep Hgb A1C less than 7%. If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? a) Consume a diet low in fats. b) Reduce total caloric intake. c) Increase intake of olive oil. d) The lipid levels are normal.

d) The lipid levels are normal. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? a. "This is a noninvasive test performed to assess your heart rhythm." b. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." c. "This is a painless test that is done to assess the structure of your heart using sound waves." d. "This test evaluates you for potentially fatal cardiac rhythms."

d. "This test evaluates you for potentially fatal cardiac rhythms." EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? a. Saline infusion b. Morphine sulfate c. No treatment, continue monitoring d. Intravenous furosemide

d. Intravenous furosemide Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? a. Assess preprocedure medications the client took that day. b. Have the client sign the consent form before the procedure is performed. c. Educate the client about the need to remain on bedrest after the procedure. d. Obtain client vital signs and a resting electrocardiogram (ECG).

d. Obtain client vital signs and a resting electrocardiogram (ECG). Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? a. Auscultate the client's precordium for murmurs. b. Teach the client about the reason for the TEE. c. Reassure the client that the test is painless. d. Validate that the client has remained NPO.

d. Validate that the client has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? a. Men do not tend to report chest pain. b. Men are more likely than women to die after MI. c. Men more than women tend to deny the importance of symptoms. d. Women may experience extreme fatigue and dizziness as sole symptoms.

d. Women may experience extreme fatigue and dizziness as sole symptoms. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.

A patient has a normal cardiac rhythm strip except that the PR interval is 0.34 seconds. The appropriate intervention by the nurse is to ________________

document the finding and continue to monitor the patient.

The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that ________________

every other QRS complex is wide and starts prematurely.

nitrates stimulate....

guanylyl cyclase --> cGMP --> vasodilation

A patient who has a history of sudden cardiac death has an ICD inserted. When performing discharge teaching with the patient, it is important for the nurse to instruct the patient and family that ______________

if the ICD fires and the patient loses consciousness, 911 should be called.

when are immediate release dihydropyridine CCBs contraindicated

in the absence of a beta blocker

A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the drug has been effective on finding a(n) _________________

increase in the patient's heart rate.

Angiotensin 2 Receptor Blockers (ARB's)

losartan Valsartan

prasugrel and ticagrelor are less/more effective platelet inhibitors

more effective, faster onset of action