Care for Cardiac Patients: Acute Coronary Syndrome

B (A description of the chest discomfort must be obtained first, before further action can be taken.Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.)

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A. Administers oxygen therapy B. Obtains the client's description of the chest discomfort C. Provides pain relief medication D. Remains calm and stays with the client

B (The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL per hour is excessive.Although hypothermia is a common problem after surgery, a temperature of 98.2°F (36.8°C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.)

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? A. Temperature 98.2°F (36.8°C) B. Chest tube drainage 175 mL last hour C. Serum potassium 3.9 mEq/L (3.9 mmol/L) D. Incisional pain 6 on a scale of 0 to 10

C (The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.)

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? A. "This way you will not need to have a leg incision." B. "The surgeon prefers this approach because it is easier." C. "These arteries remain open longer." D. "The surgeon has chosen this approach because of your age."

A (The statement by the client that unstable angina being a big warning and needing to alter his lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of unstable angina and/or MI.Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.)

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? A. "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." B. "Angina is just a temporary interruption of blood flow to my heart." C. "I need to tell my wife I've had a heart attack." D. "Because this was temporary, I will not need to take any medications for my heart."

A (The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.)

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? A. The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea B. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min D. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

B (During and after thrombolytic administration, facial drooping may indicate intracranial bleeding, including changes in neurologic status.A 1-inch (2.5 cm) backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value which is 1½ to 2½ times the control. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.)

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A. A 1-inch (2.5 cm) backup of blood in the IV tubing B. Facial drooping C. Partial thromboplastin time (PTT) 68 seconds D. Report of chest pressure during dye injection

C (The nurse will assign a stable 66-year-old client with a prescription for a nitroglycerin patch to the LPN/LVN. The LPN/LVN scope of practice includes administration of medications to stable clients.Third-degree heart block is characterized by a very low heart rate and usually requires pacemaker insertion. The skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability. This client will need medications and monitoring beyond the scope of practice of the LPN/LVN.)

An LPN/LVN is scheduled to work on the inclient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A. A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. B. A 62-year-old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8°F (38.2°C). C. A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is stable and scheduled for discharge to a group home later today. D. A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia.

C (In this situation, the nurse next needs to assess pulmonary wedge pressure (PAWP). Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation. Hypotension could cause the graft to collapse.Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated. Further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia. Giving loop diuretics increases hypovolemia.)

An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? A. No action is required; low blood pressure is normal for older adults. B. No action is required for postsurgical CABG clients. C. Assess pulmonary artery wedge pressure (PAWP). D. Give ordered loop diuretics.

ventricular remodeling

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are prescribed within 48 hours of ACS if ejection fraction is less than or equal to 40% to prevent ___________________ and the development of heart failure. Both ACEIs and ARBs increase survival after an MI.

Beta Blockers

Cardioselective ___________________ are usually given within the first few hours after the MI patient is stable as a way to (1) decrease the size of the infarct, (2) decrease the occurrence of ventricular dysrhythmias, and (3) decrease mortality rates.

Q

Changes in the ____ wave of the ECG waveform (deeper and longer wave) indicate that the myocardial infarction has progressed and irreversible necrosis has occurred.

D (In this situation, the best response by the nurse is to ask the client where he or she might be able to walk. This calls for cooperation and participation from the client. Increased activity is imperative for this client.Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.)

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? A. "You are right. Work on your diet then." B. "You must find someplace to walk." C. "Walk around the edge of your apartment complex." D. "Where might you be able to walk?"

cough

If the balloon remains in the wedge position after PAWP measurement, try to change the catheter's position by asking the patient to _________ or by changing his or her position. If these methods are not successful, notify the physician immediately.

cardiac tamponade

Manifestations of _______________________ following a CABG procedure include cessation of previously heavy mediastinal drainage, jugular venous distention with clear lungs, pulsus paradoxus, equalizing of wedge pressure and right atrial pressure, and cardiovascular collapse.

atherosclerosis

Most MIs are the result of ___________________ of a coronary artery, rupture of the plaque, subsequent thrombosis, and occlusion of blood flow.

ischemia

Non ST-segment elevation MI (NSTEMI) inficates myocardial _____________

phosphodiesterase inhibitors

Patients may take nitroglycerin to relieve episodic anginal pain. Before administering nitroglycerin, ensure that the patient has not taken any _______________________________________ for erectile dysfunction, such as sildenafil (Viagra, Revatio) or tadalafil (Cialis), within the past 24 to 48 hours as this can cause profound hypotension. Blood pressure should be monitored carefully in the patient receiving nitroglycerin, especially when given IV.

diabetic neuropathy

Patients with diabetes mellitus and CAD may not experience chest pain or pressure due to ____________________________.

B (The focus of pain relief is to improve oxygen supply and to reduce myocardial oxygen demand.Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain does not mean that the MI is resolving. Although it is used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.)

Prompt pain management with myocardial infarction is essential for which reason? A. The discomfort will increase client anxiety and reduce coping. B. Pain relief improves oxygen supply and decreases oxygen demand. C. Relief of pain indicates that the MI is resolving. D. Pain medication would not be used until a definitive diagnosis has been established.

infarction (necrosis)

ST-segment elevation MI (STEMI) indicates myocardial ___________________.

CO (cardiac output) Electrolytes Blood counts

State three priority things the nurse should assess in a post-CABG patient.

B (Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.)

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? A. Urine output of 1500 mL on the preceding day B. Crackles in the lung fields C. Pedal edema D. Expectoration of yellow sputum

B (The client with the third-degree heart block needs to be seen first. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion.A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled)

The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client does the nurse see first? A. Client with normal sinus rhythm and PR interval of 0.28 second B. Client with third-degree heart block on the monitor C. Client with dyspnea on exertion when ambulating to the bathroom D. Client who refuses to take heparin or nitroglycerin

D (Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.)

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? A. Substernal chest discomfort occurring at rest B. Chest pain brought on by exertion or stress C. Substernal chest discomfort relieved by nitroglycerin or rest D. Substernal chest pressure relieved only by opioids

D (The activity should be terminated when the nurse notices the client's respiration rate of 28 breaths per minute. This indicates tachypnea and possibly tachycardia due to activity intolerance.Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.)

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? A. Pulse 60 beats/min and regular B. Urinary frequency C. Incisional discomfort D. Respiratory rate 28 breaths/min

C (Placing a chair in the shower is an activity performed in Phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.)

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? A. The need to increase activities slowly at home B. Planning and participating in a walking program C. Placing a chair in the shower for independent hygiene D. Consultation with social worker for disability planning

B (The client with an anterior wall MI is most carefully observed for the development of left ventricular failure. Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of left ventricular contraction, leading to heart failure.The client with an inferior wall MI is most likely to develop right ventricular heart failure related to an occlusion of the right coronary artery. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.)

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? A. Inferior wall B. Anterior wall C. Lateral wall D. Posterior wall

BCE (The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/minute is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.)

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. A. Bradycardia B. Cool, diaphoretic skin C. Crackles in the lung fields D. Respiratory rate of 12 breaths/min E. Anxiety and restlessness F. Temperature of 100.4°F (38.0°C)

ABDE (Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.)

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. A. Truncal obesity B. Hypercholesterolemia C. Elevated homocysteine levels D. Glucose intolerance E. Client taking losartan (Cozaar)

C (The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.)

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? A. Reduce abdominal fat. B. Avoid stress. C. Do not smoke or chew tobacco. D. Avoid alcoholic beverages.

C (The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death.Assessing mental status, coping skills, or postoperative pain is not the priority for this client.)

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? A. Assess coping skills. B. Assess for postoperative pain at the client's incision site. C. Monitor the heart rate for dysrhythmias. D. Monitor mental status.

D (Positive findings for troponin is the most specific cardiac marker used to determine whether an MI has occurred.Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.)

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? A. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase B. Homocysteine and C-reactive protein C. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol D. Troponin

10 minutes

Twelve-lead ECGs identify the lead(s) in which ECG changes are occurring and the location of ischemia or necrosis. o The ECG should be obtained within _________________ (how long?) for a patient who presents with chest discomfort.

S3

What adventitious heart sound is indicative of heart failure in the patient with an MI?

high blood pressure (or taking BP meds) low HDL (<45mg/dL for men, <55 for women) high triglycerides (150mg/dL or higher, or taking a med for it) high fasting blood glucose (Diabetes, glucose intolerance) large waist size (>40 inches in men, >35 in women)

What are the five components of metabolic syndrome?

dysrhythmia

What is the number one complication of MI?

HF (cardiac failure, and also infection, fluid/electrolyte imbalance, bleeding)

What is the number one complication post CABG procedure?

ABC (Administering oxygen will increase available oxygen for the ischemic myocardium during the acute phase of an MI. Morphine is also needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain.Naloxone is a narcotic antagonist that is used for over dosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.)

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction (MI)? Select all that apply. A. Oxygen B. Morphine sulfate C. Nitroglycerin D. Naloxone E. Acetaminophen F. Verapamil (Calan, Isoptin)

BCD (Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue.Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.)

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? Select all that apply. A. Sharp, inspiratory chest pain B. Dyspnea C. Dizziness D. Extreme fatigue E. Anorexia

BCD (Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.)

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. A. Premenopausal B. Increasing age C. Family history D. Abdominal obesity E. Breast cancer

D (In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client's angina may not be eliminated. Reocclusion is possible after PTCA.The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.)

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? A. "I will be awake during this procedure." B. "I will have a balloon in my artery to widen it." C. "I must lie still after the procedure." D. "My angina will be gone for good."

metabolic syndrome

______________: A syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes.