Chapter 27- PrepU Adult Health
A client presents to the emergency department reporting chest pain. Which order should the nurse complete first? 12-lead ECG 2 L oxygen via nasal cannula Troponin level Aspirin 325 mg orally
12-lead ECG Explanation: The nurse should complete the 12-lead ECG first. The priority is to determine whether the client is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.
Which medication is an antidote to heparin? Protamine sulfate Alteplase Clopidogrel Aspirin
Protamine sulfate Explanation: Protamine sulfate is known as the antagonist to heparin. Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.
The nurse is teaching a client with suspected acute myocardial infarction about serial isoenzyme testing. When is it best to have isoenzyme creatinine kinase of myocardial muscle (CK-MB) tested? 30 minutes to 1 hour after pain 2 to 3 hours after admission 4 to 6 hours after pain 12 to 18 hours after admission
4 to 6 hours after pain Explanation: Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.
The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol? Digoxin Atropine Protamine sulfate Sodium nitroprusside
Atropine Explanation: Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.
A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? Pulse rate of 84 beats/minute Respiration 26 breaths/minute Blood pressure 84/52 mm Hg Temperature of 100.2° F (37.9° C)
Blood pressure 84/52 mm Hg Explanation: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.
A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent? Clopidogrel Isosorbide mononitrate Metoprolol Diltiazem
Clopidogrel Explanation: Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.
A nurse is caring for a client after cardiac surgery. Upon assessment, the client appears restless and reports nausea and weakness. The client's ECG reveals peaked T waves. The nurse reviews the client's serum electrolytes, anticipating which abnormality? Hyperkalemia Hypercalcemia Hypomagnesemia Hyponatremia
Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without changes in T-wave formation.
A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? Prolonged PR interval Absent Q wave Elevated ST segment Widened QRS complex
Elevated ST segment Explanation: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.
Which of the following is inconsistent as a condition related to metabolic syndrome? Hypotension Insulin resistance Abdominal obesity Dyslipidemia
Hypotension Explanation: A diagnosis of metabolic syndrome includes three of the following conditions: insulin resistance, abdominal obesity, dyslipidemia, hypertension, proinflammatory state, and prothrombotic state.
The nurse notes that the post cardiac surgery client demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025). What will the nurse anticipate the health care provider will order? Increase intravenous fluids Decrease intravenous fluids Irrigate the urinary catheter Prepare the client for dialysis
Increase intravenous fluids Explanation: Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. The health care provider may increase intravenous fluids. Irrigating the urinary catheter will be done if there is a suspected blockage. Dialysis is not indicated by urinary volumes.
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is? Described as crushing and substernal Associated with nausea and vomiting Relieved by rest and nitroglycerin Accompanied by diaphoresis and dyspnea
Relieved by rest and nitroglycerin Explanation: One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.
The nurse is beginning discharge teaching with a client diagnosed with a myocardial infarction (MI). The nurse will include teaching on what medications? Select all that apply. morphine atorvastatin enalapril aspirin sildenafil
atorvastatin enalapril aspirin Explanation: Upon client discharge, there needs to be documentation that the client was discharged on a statin (atorvastatin), an ACE or angiotensin receptor blocking agent (enalapril), and aspirin. Morphine is used to reduce the client's pain and anxiety. Sildenafil is a medication used for pulmonary hypertension.
A client who had coronary artery bypass surgery is exhibiting signs of heart failure. What medications will the nurse anticipate administering for this client? Select all that apply. diuretics inotropic agents digoxin amlodipine nitroprusside
diuretics inotropic agents digoxin Explanation: Medical management of cardiac failure includes digoxin, diuretics, and IV inotropic agents. Amlodipine and calcium channel blockers are not used due to systolic dysfunction. Nitroprusside is a vasodilator that is not used for heart failure.
A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? blood pressure of 129/72 mm Hg heart rate of 87 bpm hemoglobin of 16 g/dL hematocrit of 30%
hematocrit of 30% Explanation: Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.
The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as high. low. within normal limits. critically high.
high. Explanation: Treatment of blood cholesterol to reduce cardiovascular risk in adults calls for a fasting lipid profile to demonstrate an LDL value below 100 mg/dL (or less than 70 mg/dL for very high-risk clients). An LDL level of 115 mg/dL is higher than the target for treatment.
The nurse is caring for a client who is having chest pain associated with a myocardial infarction (MI). What medication will the nurse administer intravenously to reduce pain and anxiety? fentanyl hydromorphone hydrochloride morphine sulfate codeine sulfate
morphine sulfate Explanation: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine is the drug of choice to reduce pain and anxiety. It also reduces preload and afterload, decreasing the work of the heart. Fentanyl, hydromorphone, and codeine sulfate are opioids but do not reduce preload and afterload.
The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome? pericardial friction rub hypothermia decreased white blood cell (WBC) count decreased erythrocyte sedimentation rate (ESR)
pericardial friction rub Explanation: Post-pericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of post-pericardiotomy syndrome.
A client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must determine whether the client has which absolute contraindication to thrombolytic therapy? prior intracranial hemorrhage recent consumption of a meal shellfish allergy use of heparin
prior intracranial hemorrhage Explanation: History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.
