L7 CARDIAC

Health Promotion and Maintenance 2. To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective? a. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. b. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet. c. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. d. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.

A Rationale: Lifestyle changes are more likely to be successful when consideration is given to patient's 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. Removing saturated fat from the diet completely 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. Cognitive Level: Application Text Reference: pp. 792-793 Nursing Process: Implementation

Physiological Integrity 15. 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 a. acute pain related to myocardial ischemia. b. anxiety related to perceived threat of death. c. decreased cardiac output related to cardiogenic shock. d. activity intolerance related to decreased cardiac output.

A Rationale: All the nursing diagnoses may be appropriate for this patient, but the data indicate that the priority diagnosis is pain, a physiologic stressor. The patient's anxiety will also be reduced if the pain is resolved. There are no data indicating that the patient is experiencing cardiogenic shock or activity intolerance. Cognitive Level: Application Text Reference: pp. 806, 811, 813 Nursing Process: Diagnosis

Physiological Integrity 12. 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) a. increase in the patient's heart rate. b. increase in peripheral pulse volume. c. decrease in ventricular response. d. decrease in premature contractions.

A Rationale: Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. Ventricular response will be increased by atropine because of the improvement in AV conduction. Atropine will not decrease PVCs, and the patient does not have PVCs. Cognitive Level: Application Text Reference: p. 853 Nursing Process: Evaluation

Physiological Integrity 13. The nurse has received the laboratory results for a patient who developed chest pain 2 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. troponins T and I. b. creatine kinase-MB. c. LDL cholesterol. d. C-reactive protein.

A Rationale: Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium. Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 4 to 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction. Cognitive Level: Application Text Reference: pp. 751-752 Nursing Process: Assessment

Physiological Integrity 31. 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? a. Administration of the ordered metoprolol (Lopressor) and aspirin b. Evaluating the patient's response to ambulation in the hallway c. Teaching the patient about the pathophysiology of heart disease d. Completing the documentation for a home health nurse referral

A Rationale: LPN/LVN education and scope of practice include safe administration of medications. Evaluating the patient response to exercise after an AMI 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. Cognitive Level: Application Text Reference: pp. 810-817 Nursing Process: Evaluation

Physiological Integrity 5. A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring? a. MCL1 b. AVF c. V6 d. I

A Rationale: Leads II and MCL1 are the best leads for visualization of P waves, which reflect atrial activity. The other leads are less commonly used for continuous monitoring, since they do not usually demonstrate the P wave and QRS activity as well. Cognitive Level: Application Text Reference: p. 843 Nursing Process: Implementation

Health Promotion and Maintenance 6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

A Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. Cognitive Level: Analysis Text Reference: pp. 828-829 Nursing Process: Implementation

Physiological Integrity 21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. b. improve the ability of the ventricular myocardium to contract, strengthening contractility. c. enhance the speed of impulse conduction through the heart, increasing the heart rate. d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

A Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart. Cognitive Level: Application Text Reference: p. 829 Nursing Process: Implementation

Physiological Integrity 11. 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? a. Troponin levels b. C-reactive protein c. High-density lipoprotein (HDL) cholesterol d. Homocysteine

A Rationale: Troponin levels increase about 3 hours after the onset of MI. The other laboratory data are useful in determining the patient's risk for developing CAD but are not helpful in determining whether an acute MI is in progress. Cognitive Level: Application Text Reference: pp. 805-806 Nursing Process: Assessment

Physiological Integrity 15. The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left 5th intercostal space and midclavicular line. The best way to record this information is a. "systolic murmur heard at mitral area." b. "diastolic murmur heard at aortic area." c. "systolic murmur heard at Erb's point." d. "diastolic murmur heard at tricuspid area."

A Rationale: The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and 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 5th intercostal space and the midclavicular line. The aortic area is located at the 2nd intercostal space along the right sternal border. Erb's point is located at the 3rd intercostal space along the left sternal border. The tricuspid area is located at the 5th intercostal space along the left sternal border. Cognitive Level: Application Text Reference: pp. 749-751 Nursing Process: Assessment

Physiological Integrity 18. The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for a. relief of chest discomfort. b. a decreased heart rate. c. an increase in BP. d. fewer cardiac dysrhythmias.

A Rationale: The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. Increases in heart rate and a drop in BP are common side effects of nitroglycerin. Nitroglycerin does not directly impact cardiac dysrhythmias. Cognitive Level: Application Text Reference: pp. 806, 808 Nursing Process: Evaluation

Physiological Integrity 11. 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 a. third-degree AV block. b. sinus rhythm with premature atrial contractions (PACs). c. sinus rhythm with PVCs. d. junctional escape rhythm.

A Rationale: The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs or PVCs will have a normal rate and consistent PR intervals with occasional PACs or PVCs. A junctional escape rhythm will not have P waves. Cognitive Level: Application Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 22. A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST-segment elevation on the ECG d. An increase in cardiac enzyme levels since admission

A Rationale: The ongoing chest pain indicates continued myocardial injury and necrosis. The nurse should notify the physician. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected even with reperfusion. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation

Psychosocial Integrity 18. 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, a. "I won't lift the arm on the pacemaker side up very high until I see the doctor." b. "I will notify the airlines when I make a reservation that I have a pacemaker." c. "I must avoid cooking with a microwave oven or being near a microwave in use." d. "It will be 6 weeks before I can take a bath or return to my usual activities."

A Rationale: The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The pacemaker rarely sets off an airport security alarm and there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. Cognitive Level: Application Text Reference: p. 861 Nursing Process: Evaluation

Physiological Integrity 19. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first? a. Make the patient NPO. b. Start a large-gauge IV line. c. Administer O2 per mask. d. Give lorazepam (Ativan) 1 mg IV.

A Rationale: 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 will also need to be accomplished, but not until just before or during the procedure. Cognitive Level: Application Text Reference: p. 754 Nursing Process: Implementation

Health Promotion and Maintenance 19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment

Physiological Integrity 14. 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 a. start basic cardiopulmonary resuscitation (CPR). b. administer an IV bolus dose of epinephrine. c. prepare the patient for endotracheal intubation. d. wait for the defibrillator to arrive.

A Rationale: The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; therefore, the initial actions include calling for help, and initiating CPR until defibrillation is possible. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, CPR should be continued and IV medications and endotracheal intubation should be initiated. Cognitive Level: Application Text Reference: p. 855 Nursing Process: Implementation

Health Promotion and Maintenance 8. During physical examination of a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. The nurse teaches the patient that this is a. a normal assessment finding for a thin individual. b. likely to be caused by age-related sclerosis and inelasticity of the aorta. c. an indication that an abdominal aortic aneurysm has probably developed. d. evidence of elevated systemic arterial pressure.

A Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. More data would be needed to support a diagnosis of aortic sclerosis, aortic aneurysm, or hypertension. Cognitive Level: Application Text Reference: p. 750 Nursing Process: Assessment

Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 35: Nursing Management: Heart Failure MULTIPLE CHOICE 1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment

Physiological Integrity 12. 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. heave. d. murmur.

B Rationale: 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. Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the heart. Cognitive Level: Comprehension Text Reference: pp. 748, 750 Nursing Process: Assessment

Health Promotion and Maintenance 14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about a. an apical pulse rate of 106 beats/min. b. an oxygen saturation of 88% on room air. c. weight gain of 1 kg (2.2 lb) over 24 hours. d. decreased hourly patient urinary output.

B Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. Cognitive Level: Analysis Text Reference: pp. 829-830 Nursing Process: Assessment

Physiological Integrity 22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Teach the patient the reasons for remaining on bed rest. b. Monitor the patient's BP every hour. c. Adjust the drip rate to keep the systolic BP >90 mm Hg. d. Call the health care provider about a decrease in urine output.

B Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output. Cognitive Level: Application Text Reference: pp. 827-829 Nursing Process: Planning

Physiological Integrity 34. 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 a. the pathophysiology of coronary artery disease. b. when patient cardiac rehabilitation will begin. c. home-discharge drugs such as aspirin and -blockers. d. typical emotional responses to MI.

B Rationale: At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as CAD pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to MI. Cognitive Level: Application Text Reference: p. 813 Nursing Process: Planning

Physiological Integrity 14. Nadolol (Corgard) is prescribed for a patient with angina. In evaluating the effectiveness of the drug, the nurse will monitor for a. improvement in the quality of the peripheral pulses. b. ability to do daily activities without chest discomfort. c. decreased BP and apical pulse rate. d. fewer complaints of having cold hands and feet.

B Rationale: Because the medication is ordered to improve the patient's angina, so effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. BP and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The non-cardioselective -blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature. Cognitive Level: Application Text Reference: p. 810 Nursing Process: Evaluation

Physiological Integrity 28. 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? a. Have the family members encourage the patient to continue planning for the vacation. b. Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI. c. Implement reality orientation by reminding the patient several times a day about the MI. d. Begin teaching the patient about the normal functions of the heart to improve understanding of the MI.

B Rationale: Denial is a normal coping mechanism after an acute episode like an MI; waiting until the patient asks questions will improve the patient's ability to take in needed information. The patient should not be encouraged to leave for a vacation during the MI recovery period. Reminding the patient about the MI is likely to make the patient angry and lead to distrust of the nursing staff. The patient in denial will not be interested in learning about the normal functions of the heart. Cognitive Level: Application Text Reference: p. 814 Nursing Process: Planning

Physiological Integrity 8. 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 a. prepare the patient for temporary pacemaker insertion. b. document the finding and continue to monitor the patient. c. notify the health care provider immediately. d. administer atropine per protocol.

B Rationale: First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine or a pacemaker is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. Cognitive Level: Application Text Reference: p. 853 Nursing Process: Implementation

Physiological Integrity 27. 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 a. that sudden cardiac death events rarely reoccur. b. about the purpose of outpatient Holter monitoring. c. how to self-administer low-molecular-weight heparin. d. to limit activities after discharge to prevent future events.

B Rationale: Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, which can occur even when the patient is resting. Cognitive Level: Application Text Reference: p. 818 Nursing Process: Planning

Physiological Integrity 5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture.

B Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle). Cognitive Level: Application Text Reference: p. 822 Nursing Process: Planning

Physiological Integrity 19. 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 a. medications will no longer be needed to control dysrhythmias. b. if the ICD fires and the patient loses consciousness, 911 should be called. c. CPR may displace the ICD leads and should not be performed. d. the ICD rarely triggers airport security alarms and travel without restrictions is allowed.

B Rationale: If the ICD fires and the patient continues to have symptoms of cardiac arrest, activation of the emergency response system is indicated. The patient is likely to continue on medications to control dysrhythmias. If the patient experiences cardiac arrest, CPR should be performed. ICDs do trigger airport security alarms, and the patient will need to notify airport personnel about the presence of the device. Cognitive Level: Application Text Reference: p. 858 Nursing Process: Implementation

Physiological Integrity 8. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion.

B Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment

Health Promotion and Maintenance 11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload. Cognitive Level: Application Text Reference: pp. 827-828 Nursing Process: Planning

Physiological Integrity 12. Nifedipine (Procardia) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that Procardia will a. help to prevent clotting in the coronary arteries. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. reduce the "fight or flight" response.

B Rationale: Prinzmetal's angina is caused by coronary artery spasm. Calcium-channel blockers (e.g., nifedipine) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help to prevent coronary artery thrombosis, and -blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. Cognitive Level: Application Text Reference: p. 801 Nursing Process: Implementation

Physiological Integrity 7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

B Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy. Cognitive Level: Application Text Reference: p. 828 Nursing Process: Evaluation

Physiological Integrity 10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. says that the nitroglycerin patch will be used for any chest pain that develops. b. calls when the weight increases from 124 to 130 pounds in a week. c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. d. makes an appointment to see the doctor at least once yearly.

B Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination. Cognitive Level: Application Text Reference: pp. 826, 833-834, 838 Nursing Process: Evaluation

Physiological Integrity 5. During a physical examination of a patient, the nurse palpates the PMI in the sixth intercostal space lateral to the midclavicular line. The most appropriate action for the nurse to take next will be to a. document that the PMI is in the normal location. b. assess the patient for symptoms of left ventricular hypertrophy. c. ask the patient about risk factors for coronary artery disease. d. auscultate both the carotid arteries for a bruit.

B Rationale: The PMI should be felt at the intersection of the 5th intercostal space and the 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 coronary or carotid artery disease. Cognitive Level: Application Text Reference: pp. 750-751 Nursing Process: Assessment

Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 36: Nursing Management: Dysrhythmias MULTIPLE CHOICE 1. 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 a. P wave. b. PR interval. c. QRS complex. d. QT interval.

B Rationale: The PR interval represents depolarization of the atria, AV node, bundle of His, bundle branches, and the Purkinje fibers, up to the point of depolarization of the ventricular cells. The P wave represents atrial depolarization. The QRS represents ventricular depolarization. The QT interval represents depolarization of the depolarization and repolarization of the entire conduction system. Cognitive Level: Comprehension Text Reference: pp. 846-847 Nursing Process: Assessment

Physiological Integrity 10. 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 a. notify the health care provider. b. administer IV antidysrhythmic drugs per protocol. c. defibrillate the patient. d. document the rhythm and continue to monitor the patient.

B Rationale: The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. Cognitive Level: Application Text Reference: p. 855 Nursing Process: Implementation

Physiological Integrity 17. The 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. places the patient in the left lateral position to check for the PMI. d. uses the palm of the hand to assess extremity skin temperature.

B Rationale: 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. Cognitive Level: Application Text Reference: p. 748 Nursing Process: Assessment

Physiological Integrity 15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term-care facility. d. arrangements for around-the-clock care.

B Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient to develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term-care, or around-the-clock home care. Cognitive Level: Application Text Reference: pp. 836-837 Nursing Process: Assessment

Physiological Integrity 7. 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? a. Heart rate 100 beats/min b. Chest pain level 8 on a 10-point scale c. Blood pressure (BP) 104/56 mm Hg d. Pedal pulses 2+

B Rationale: The patient's chest pain may indicate that restenosis of the coronary artery is 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. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Physiological Integrity 25. 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 a. ineffective coping related to depression and anxiety. b. situational low self-esteem related to perceived role changes. c. impaired adjustment related to unwillingness to alter lifestyle. d. ineffective health maintenance related to lack of knowledge.

B Rationale: The patient's statements indicate that the perceived change in role is the major concern. The patient is experiencing progression through the normal stages of loss and grief that often occur after an MI, so ineffective coping is not an appropriate diagnosis. There is no evidence to support an unwillingness to alter lifestyle or ineffective health maintenance. Cognitive Level: Application Text Reference: pp. 813-814 Nursing Process: Diagnosis

Physiological Integrity 4. When reviewing the 12-lead ECG for a healthy 86-year-old patient who is having an annual physical examination, which of these observations will be of most concern to the nurse? a. The PR interval is 0.21 seconds. b. The HR is 43 beats/min. c. There is a right bundle-branch block. d. There is a QRS duration of 0.13 seconds.

B Rationale: 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, the bundle of His, and the bundle branches. Cognitive Level: Application Text Reference: p. 744 Nursing Process: Assessment

Physiological Integrity 7. The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that a. there are pairs of wide and distorted QRS complexes. b. every other QRS complex is wide and starts prematurely. c. all QRS complexes are wide and the rate is 150 to 250 beats/min. d. there are premature QRS complexes with two different shapes.

B Rationale: Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. Wide QRS complexes at a rate of 150 to 250 indicate ventricular tachycardia. Wide QRS complexes with different shapes are described as multifocal premature ventricular contractions (PVCs). Cognitive Level: Comprehension Text Reference: p. 854 Nursing Process: Assessment

Psychosocial Integrity 29. 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, a. "I will need to take an aspirin a day after the surgery to keep the graft open." b. "I will have incisions in my leg where they will remove the vein." c. "They will stop my heart and circulate my blood with a machine during the surgery." d. "They will use an artery near my heart to bypass the area that is obstructed."

B Rationale: When the internal mammary artery is used, there will be 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. Cognitive Level: Application Text Reference: p. 809 Nursing Process: Evaluation

Physiological Integrity 2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet. b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.

C Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action. Cognitive Level: Application Text Reference: p. 826 Nursing Process: Assessment

Physiological Integrity 9. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. a catheter will be inserted into a vein in the arm or leg and advanced to the heart. b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias. c. a feeling of warmth may be experienced as the contrast material is injected into the catheter. d. it will be important to lie completely still during the coronary angiography procedure.

C Rationale: A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The catheter is inserted in an artery (typically the femoral artery) and advanced to the openings for the coronary arteries at the aortic root. Dysrhythmias may occur during the procedure, but most patients are discharged a few hours after the coronary arteriogram or angiogram is completed. The patient is not required to be completely immobile during the procedure. Cognitive Level: Application Text Reference: pp. 755, 759 Nursing Process: Implementation

Physiological Integrity 37. The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first? a. A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge c. A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old who has a scheduled dose of atenolol (Tenormin) 25 mg PO due

C Rationale: After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Physiological Integrity 9. Which of these statements made by a patient after the nurse has completed teaching about the TLC diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% or nonfat milk." b. "I like fresh salmon and I will plan to eat it more often." c. "I will miss being able to eat peanut butter sandwiches." d. "I can have a cup of coffee with breakfast if I want one."

C Rationale: 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. Cognitive Level: Application Text Reference: p. 793 Nursing Process: Evaluation

Analysis 20. 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 a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

C Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. Cognitive Level: Application Text Reference: p. 827 Nursing Process: Assessment

Physiological Integrity 17. While admitting a patient with an AMI, which action should the nurse carry out first? a. Assess peripheral pulses. b. Check the oxygen saturation. c. Attach the cardiac monitor. d. Obtain the BP.

C Rationale: Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions are also important and should be accomplished as quickly as possible. Cognitive Level: Application Text Reference: pp. 799, 806 Nursing Process: Implementation

Physiological Integrity 14. When performing an assessment of a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next? a. Palpate the quality of the peripheral pulses. b. Compare the apical and radial pulse rates. c. Assess for murmurs. d. Locate the PMI.

C Rationale: Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is heard, 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 thrill. Cognitive Level: Application Text Reference: pp. 748-749, 751 Nursing Process: Assessment

Physiological Integrity 5. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient rates the pain at a level 3 to 5 (0-10 scale). b. The patient states that the pain "wakes me up at night." c. The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet. d. The patient says that the frequency of the pain has increased over the last few weeks.

C Rationale: 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. Cognitive Level: Application Text Reference: p. 798 Nursing Process: Assessment

Physiological Integrity 6. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. diaphragm of the stethoscope with the patient in a reclining position. b. diaphragm of the stethoscope with the patient lying flat on the left side. c. bell of the stethoscope with the patient in the left lateral position. d. bell of the stethoscope with the patient sitting and leaning forward.

C Rationale: 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. Cognitive Level: Application Text Reference: pp. 750-751 Nursing Process: Assessment

Physiological Integrity 16. A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Heparin will dissolve the clot that is blocking blood flow to the heart. b. Coronary artery plaque size and adherence are decreased with heparin. c. Heparin will prevent the development of clots in the coronary arteries. d. Platelet aggregation is enhanced by IV heparin infusion.

C Rationale: 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. Cognitive Level: Comprehension Text Reference: p. 800 Nursing Process: Implementation

Health Promotion and Maintenance 16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. Cognitive Level: Application Text Reference: pp. 832-833 Nursing Process: Assessment

Physiological Integrity 3. A patient has a junctional escape rhythm on the monitor. The nurse would expect the patient to have a pulse rate of ____ beats/min. a. 15-20 b. 20-40 c. 40-60 d. 60-100

C Rationale: If the SA node fails to discharge, the junction will automatically discharge at the normal junctional rate of 40 to 60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/min. Cognitive Level: Comprehension Text Reference: pp. 846-847, 852 Nursing Process: Assessment

Physiological Integrity 15. 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 a. medications. b. recent electrolyte values. c. apical radial heart rate. d. oxygen saturation.

C Rationale: It is important to assess the patient's apical-radial pulse rate because PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse, which can lead to a pulse deficit. Electrolyte imbalances, hypoxia, and certain medications may precipitate PVCs. Cognitive Level: Comprehension Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 13. A patient with chronic stable angina is being treated with metoprolol (Lopressor). The nurse will suspect that the patient is experiencing a side effect of the metoprolol if a. the patient is restless and agitated. b. the BP is 190/110 mm Hg. c. the cardiac monitor shows a heart rate of 45. d. the patient complains about feeling anxious.

C Rationale: Patients taking -blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restless, agitation, hypertension, and anxiety will not be side effects. Cognitive Level: Application Text Reference: p. 801 Nursing Process: Evaluation

1. While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. The nurse will anticipate that the patient may require a. hourly blood pressure (BP) checks. b. a coronary arteriogram. c. electrocardiographic (ECG) monitoring. d. a 2-D echocardiogram.

C Rationale: Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be cardiac dysrhythmias that would be detected with ECG monitoring. Frequent BP monitoring, coronary arteriograms, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the reason for the pulse deficit. Cognitive Level: Application Text Reference: pp. 750-751 Nursing Process: Assessment

Physiological Integrity 8. In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin (Nitrostat), the nurse identifies an expected patient outcome of a. stating that nitroglycerin is to be taken only if chest pain develops. b. listing the side effects of nitroglycerin as gastric upset and dry mouth. c. identifying the need to call the emergency medical services (EMS) if chest pain persists 5 minutes after taking nitroglycerin. d. recognizes that taking the nitroglycerin is important to decrease the ongoing atherosclerosis of the coronary arteries.

C Rationale: The EMS system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing. Gastric upset and dry mouth are not expected side effects of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. Cognitive Level: Application Text Reference: p. 798 Nursing Process: Planning

Physiological Integrity 6. 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 a. sinus tachycardia. b. atrial fibrillation. c. ventricular tachycardia. d. ventricular fibrillation.

C Rationale: The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory P waves. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. Cognitive Level: Application Text Reference: pp. 854-855 Nursing Process: Assessment

Psychosocial Integrity 35. 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? a. Have the patient take this medication with an aspirin. b. Encourage the patient to take it with a sip of water. c. Give the patient's other medications 2 hours after the Welchol. d. Administer the drug at the patient's bedtime.

C Rationale: The bile-acid sequestrants interfere with the absorption of other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the Welchol 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, Welchol should be administered with meals. Cognitive Level: Application Text Reference: pp. 794-795 Nursing Process: Implementation

Physiological Integrity 21. 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. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation

Physiological Integrity 16. When admitting a patient for a coronary arteriogram and angiogram, the assessment information that will be most important for the nurse to communicate to the health care provider is that the a. patient had an arteriogram a year ago. b. patient has not eaten anything yet today. c. patient is allergic to shellfish. d. patient's pedal pulses are +1.

C Rationale: 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 arteriogram. The other information is also communicated to the health care provider but will not require a change in the usual pre-arteriogram orders or medications. Cognitive Level: Application Text Reference: p. 755 Nursing Process: Assessment

Health Promotion and Maintenance 7. The nurse is obtaining a health history for a new patient with possible coronary artery disease. Which question would the nurse use when obtaining subjective data related to the patient's health perception-health management functional health pattern? a. "Do you every have any discomfort or indigestion resulting from exercise or activity?" b. "Have you had any recent episodes of sore throat, fever, or streptococcal infections?" c. "How frequently do you have your cholesterol level and blood pressure checked?" d. "Are there any symptoms that seem to occur when you are feeling very stressed?"

C Rationale: The health perception-health management functional pattern includes information related to what the patient knows about coronary heart disease risk factors and actions the patient is taking to decrease risk. Any patient history of streptococcal infections or sore throat would also be included in this functional pattern, but this patient has possible coronary artery disease, not rheumatic heart disease. Information about discomfort caused by activity would be included in the activity-exercise pattern. The data about symptoms in response to stress would be documented in the coping-stress tolerance functional pattern. Cognitive Level: Application Text Reference: pp. 745-746 Nursing Process: Assessment

Physiological Integrity 3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment

Physiological Integrity 3. The standard orders on the cardiac unit state, "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 a. the patient with left ventricular failure who has a BP of 110/70. b. the patient with a myocardial infarction who has a BP of 114/50. c. the postoperative patient with a BP 116/42. d. the newly admitted patient with a BP of 122/60.

C Rationale: 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. Cognitive Level: Application Text Reference: p. 744 Nursing Process: Assessment

Physiological Integrity 36. 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? a. captopril (Capoten) b. furosemide (Lasix) c. sildenafil (Viagra) d. diazepam (Valium)

C Rationale: The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using Viagra because of the risk of sudden death caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. Cognitive Level: Application Text Reference: p. 817 Nursing Process: Assessment

Physiological Integrity 11. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to a. remove the electrodes when taking a shower or tub bath. b. exercise more than usual while the monitor is in place. c. keep a diary of daily activities while the monitor is worn. d. connect the recorder to a telephone transmitter once daily.

C Rationale: 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. Cognitive Level: Application Text Reference: pp. 753, 757 Nursing Process: Implementation

Physiological Integrity 6. Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain? a. Sinus tachycardia b. Inverted T wave c. ST-segment elevation d. Frequent PACs

C Rationale: The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with PCI or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also suggest a need for therapy, but not as rapidly. Cognitive Level: Application Text Reference: p. 802 Nursing Process: Assessment

Physiological Integrity 24. After the nurse teaches a patient with chronic stable angina about how to use the prescribed nitrates, which statement by the patient indicates that the teaching has been effective? a. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." b. "I will put on the nitroglycerin patch as soon as I develop 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 keep the nitroglycerin in my kitchen window where I can find it quickly."

C Rationale: 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. Nitrates should be stored in a dark place to avoid deterioration of the medication. Cognitive Level: Application Text Reference: p. 798 Nursing Process: Evaluation

Physiological Integrity 9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

C Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate. Cognitive Level: Application Text Reference: p. 836 Nursing Process: Diagnosis

Physiological Integrity 23. 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 a. splitting of the S1 heart sound. b. S3 or S4 gallop rhythm. c. pericardial friction rub. d. holosystolic apical murmur.

C Rationale: 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. Cognitive Level: Application Text Reference: p. 805 Nursing Process: Assessment

Psychosocial Integrity 16. 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, a. "You almost died, but we were able to save you with electrical therapy." b. "You had an episode of some cardiac dysrhythmias that are common after a heart attack." c. "You had a serious abnormal heart rhythm, which treatment was able to reverse." d. "Your heart stopped beating, and we shocked you to get it started again."

C Rationale: This response honestly describes what happened to the patient while avoiding unnecessarily increasing the patient's anxiety level. More information may be given by the nurse if the patient asks further questions. The response "You had an episode of some cardiac dysrhythmias that are common after a heart attack" is not as honest and might lead to distrust of the nurse or health care system. The remaining two responses are accurate but would increase the anxiety level for many patients. Cognitive Level: Application Text Reference: p.855 Nursing Process: Implementation

Physiological Integrity MULTIPLE RESPONSE 1. When assessing a 76-year-old woman, the nurse finds the following results: BP 146/102, resting HR 104, slightly irregular S4 heart sound, and a grade I/VI aortic systolic murmur. The nurse recognizes that common effects of aging may be responsible for the (Select all that apply.) a. HR. b. irregular pulse. c. S4 heart sound. d. systolic BP. e. diastolic BP. f. grade I/VI aortic systolic murmur.

C, D, F Rationale: An S4 gallop, increased systolic BP, and aortic stenosis are associated with aging, although all these findings require further assessment or intervention. Increases in HR, irregular heart rhythms, and diastolic BP increases are not associated with increased age. Cognitive Level: Comprehension Text Reference: p. 744 Nursing Process: Assessment

Physiological Integrity 20. 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? a. BP rises from 118/60 to 126/68 mm Hg. b. Respiratory rate goes from 14 to 22 breaths/min. c. Oxygen saturation drops from 100% to 98%. d. Heart rate increases from 66 to 90 beats/min.

D Rationale: A change in heart rate of more than 20 beats or more 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. Cognitive Level: Application Text Reference: pp. 815-816 Nursing Process: Evaluation

Physiological Integrity 17. 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 a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation

Physiological Integrity 13. 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 a. IV adenosine (Adenocard). b. electrical cardioversion. c. insertion of an implantable cardioverter-defibrillator (ICD). d. anticoagulant therapy with warfarin (Coumadin).

D Rationale: Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 to 4 weeks before attempting cardioversion; this is done to prevent embolization of clots from the atria. Adenosine is not used to treat atrial fibrillation. Cardioversion may be done after several weeks of Coumadin therapy. ICDs are used for patients with recurrent ventricular fibrillation. Cognitive Level: Application Text Reference: p. 852 Nursing Process: Planning

Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 34: Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome MULTIPLE CHOICE 1. When developing a health teaching plan for a 65-year-old patient with all these risk factors for coronary artery disease (CAD), the nurse will focus on the a. family history of heart disease. b. increased risk associated with the patient's ethnicity. c. high incidence of cardiovascular disease in older people. d. low activity level the patient reports.

D Rationale: Because family history, ethnicity, and age are nonmodifiable risk factors, the nurse should focus on the patient's activity level. An increase in activity will help reduce the patient's risk for developing CAD. Cognitive Level: Application Text Reference: pp. 790-792 Nursing Process: Planning

Physiological Integrity 4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

D Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response. Cognitive Level: Application Text Reference: p. 825 Nursing Process: Evaluation

Physiological Integrity 4. 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? a. Have the patient perform the Valsalva maneuver. b. Prepare to administer -blocker medication to slow the heart rate. c. Get ready to perform electrical cardioversion. d. Obtain further information about possible causes for the heart rate.

D Rationale: The patient has sinus tachycardia, which may be caused by multiple stressors such as pain, dehydration, or myocardial ischemia; further assessment is needed before determining the treatment. Vagal stimulation and electrical cardioversion are not used to treat sinus tachycardia. -blockade may be used, but further assessment is needed first. Cognitive Level: Analysis Text Reference: p. 850 Nursing Process: Implementation

Safe and Effective Care Environment 23. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will need to include more high-potassium foods in my diet." b. "I will expect to feel more short of breath for the next few days." c. "I will be sure to take the medication after eating something." d. "I will call for help when I need to get up to the bathroom."

D Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Evaluation

Health Promotion and Maintenance 3. The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain worsens when the patient raises the arms. b. The pain increases with deep breathing. c. The pain is relieved after the patient takes nitroglycerin. d. The pain has persisted longer than 30 minutes.

D Rationale: 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 pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin. Cognitive Level: Application Text Reference: p. 803 Nursing Process: Assessment

Health Promotion and Maintenance 13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include a. avoid dietary sources of potassium because too much can cause digitalis toxicity. b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min. c. take the hydrochlorothiazide before bedtime to maximize activity level during the day. d. notify the health care provider immediately if nausea or difficulty breathing occurs.

D Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption. Cognitive Level: Application Text Reference: p. 835 Nursing Process: Implementation

Physiological Integrity 2. The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. The symptom that has the most immediate implications for the patient's care during the exercise testing is a. the BP rising from 134/68 to 150/80 mm Hg. b. the heart rate (HR) increasing from 80 to 96 beats/min. c. the patient complaining of feeling short of breath. d. the ECG indicating the presence of coronary ischemia.

D Rationale: 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 immediately terminated. Increases in BP and HR are normal responses to aerobic exercise. Shortness of breath is also normal as the intensity of exercise increases during the stress testing. Cognitive Level: Application Text Reference: pp. 753, 757 Nursing Process: Assessment

Physiological Integrity 19. 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? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"

D Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the 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 fibrinolytic therapy. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Physiological Integrity 18. A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse will explain that Holder monitoring provides information about the a. ventricular ejection fraction during usual daily activities. b. cardiovascular response to high-intensity exercise. c. changes in cardiac output when the patient is resting. d. HR and rhythm during normal patient activities.

D Rationale: Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level. Because Holter monitoring is useful only for detecting rhythm changes, it is not useful in determining ejection fraction or cardiac output. Cognitive Level: Application Text Reference: pp. 753, 757 Nursing Process: Implementation

Physiological Integrity 9. A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED). Initial laboratory findings are serum potassium 2.8 mEq/L (2.8 mmol/L), serum sodium 138 mEq/L (138 mmol/L), serum chloride 90 mEq/L (90 mmol/L), and blood glucose 628 mg/dl (34.9 mmol/L). Cardiac monitoring shows multifocal PVCs. The nurse understands that the patient's PVCs are most likely caused by a. hyperglycemia. b. hypoxemia. c. dehydration. d. hypokalemia.

D Rationale: Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. Hyperglycemia and dehydration are not associated with increased PVC risk. There is no indication that the patient is hypoxemic. Cognitive Level: Analysis Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that a. heart transplants are experimental surgeries that are not covered by most insurance. b. the patient is too old to be placed on the transplant list. c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate. d. candidacy for heart transplant depends on many factors.

D Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant. Cognitive Level: Comprehension Text Reference: p. 837 Nursing Process: Planning

Physiological Integrity 20. 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 a history of coronary artery disease. b. The patient took all the prescribed cardiac medications today. c. The patient has an allergy to shellfish and iodine. d. The patient has a permanent ventricular pacemaker in place.

D Rationale: MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information will also be reported to the health care provider but does not impact on whether or not the patient can have an MRI. Cognitive Level: Application Text Reference: p. 755 Nursing Process: Implementation

Physiological Integrity 12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products.

D Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. Cognitive Level: Application Text Reference: p. 833 Nursing Process: Implementation

Safe and Effective Care Environment 32. A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Skin flushing after taking the medications b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Generalized muscle aches and pains

D Rationale: Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and, although the nurse should follow up with the patient, do not indicate that a change in medication is needed. Cognitive Level: Application Text Reference: p. 793 Nursing Process: Evaluation

Health Promotion and Maintenance 10. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Atenolol will increase the strength of my heart muscle." b. "I can expect to feel short of breath when taking atenolol." c. "Atenolol will improve the blood flow to my coronary arteries." d. "It is important not to suddenly stop taking the atenolol."

D Rationale: Patients who have been taking -blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking -blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol is not a vasodilator and works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries. Cognitive Level: Application Text Reference: p. 801 Nursing Process: Evaluation

Physiological Integrity 30. 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 a. "Sexual intercourse may be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling." b. "You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern." c. "Sexual activity can be resumed whenever you feel like you are ready. Most sexual response is emotional rather than physical." d. "Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."

D Rationale: Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The answer beginning "Sexual intercourse may be too strenuous" may be true; however there are no data in the stem to indicate that intercourse will be too stressful to the heart for this patient. The answer beginning, "You should discuss your questions" implies that there are serious medical concerns about sexual activity. And the answer beginning "Sexual activity can be resumed whenever" is incorrect because physiologic parameters such as heart rate and BP do increase during sexual activity. Cognitive Level: Application Text Reference: p. 817 Nursing Process: Implementation

Psychosocial Integrity 26. 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? a. The oral temperature is 100.8° F (38.2° C). b. The white blood cell count (WBC) is 12,000/l. c. The patient denies ever having a heart attack. d. The lungs have crackles audible to the midline.

D Rationale: The crackles indicate that the patient may be developing heart failure, a possible complication of MI. The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. The fever and elevated WBC are normal occurrences after MI as a result of inflammation that occurs after tissue necrosis. Denial is a common response in the immediate period after the MI. Cognitive Level: Application Text Reference: p. 804 Nursing Process: Assessment

Physiological Integrity 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 a. prevent or minimize ventricular irritability. b. discharge if ventricular fibrillation occurs and prevent cardiac arrest. c. depolarize the atria and generate a P wave. d. stimulate a heart beat if the patient's own heart rate drops too low.

D Rationale: The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. A P wave will not be generated even with a dual-chamber pacemaker because the atria are already depolarizing in atrial fibrillation. Cognitive Level: Application Text Reference: pp. 858-859 Nursing Process: Implementation

Physiological Integrity 33. A patient who has chest pain is admitted to the ED, and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. CT scan d. ECG

D Rationale: The priority for the patient is to determine whether an AMI is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing an MI. Cognitive Level: Application Text Reference: p. 805 Nursing Process: Implementation

Physiological Integrity 2. When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will a. print a 1-minute ECG strip and count the number of QRS complexes. b. count the number of large squares in the R-R interval and divide by 300. c. calculate the number of small squares between one QRS complex and the next and divide into 1500. d. use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

D Rationale: This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods take longer. Cognitive Level: Comprehension Text Reference: pp. 843, 845 Nursing Process: Assessment

Physiological Integrity 4. 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 a. determine whether there are any structural defects in the chambers of the heart. b. locate any coronary artery obstructions and administer thrombolytic agents. c. measure the amount of blood being pumped from the heart with each contraction. d. visualize any coronary artery blockages and dilate any obstructed arteries.

D Rationale: Visualization of the coronary arteries and possible balloon dilation are scheduled for this patient. Thrombolytic therapy is an alternative treatment if the patient is experiencing acute coronary syndrome (ACS) but is not the ordered therapy for this patient. Although angiography might help to detect structural defects or changes in cardiac output, it is not the reason for the procedure in this patient with symptoms of CAD. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Implementation

Physiological Integrity 10. While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to a. have the patient perform the Valsalva maneuver and observe the jugular veins. b. palpate the jugular veins and compare the volume and pressure on the both sides. c. use a centimeter ruler to measure and document accurately the level of the JVD. d. elevate the patient gradually to an upright position and examine for continued JVD.

D Rationale: When assessing for and documenting JVD, the nurse should document the angle at which the patient is positioned. When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at 30 to 45 degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. Comparison of the volume and pressure of the jugular veins is not included in jugular vein assessment. Cognitive Level: Application Text Reference: pp. 748-749 Nursing Process: Assessment