Lewis 34: Nursing Mgmt: Coronary Artery Disease and Acute Coronary Syndrome, Care of Patients with Dysrhythmias

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.

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

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

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

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

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

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

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

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

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

Physiological Integrity COMPLETION 1. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.

50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30. DIF: Cognitive Level: Remember (knowledge) REF: 789-790 TOP: Nursing Process: Assessment MSC:

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

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

Safe and Effective Care Environment 13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient. DIF: Cognitive Level: Apply (application) REF: 802 TOP: Nursing Process: Implementation MSC:

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

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

Physiological Integrity 21. A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).

B In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 23. A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including oxygen saturation.

C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly. DIF: Cognitive Level: Apply (application) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. 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 This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Apply (application) REF: 789-790 TOP: Nursing Process: Assessment MSC:

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

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Physiological Integrity 25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope, but are not appropriate for syncope of unknown origin. DIF: Cognitive Level: Apply (application) REF: 807 TOP: Nursing Process: Planning MSC:

Safe and Effective Care Environment 27. Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating. DIF: Cognitive Level: Analyze (analysis) REF: 795 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).

A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate. DIF: Cognitive Level: Apply (application) REF: 796 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC:

Physiological Integrity 8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

A 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. The patient does not have premature atrial or ventricular contractions. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 14. A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal. DIF: Cognitive Level: Apply (application) REF: 793 TOP: Nursing Process: Implementation MSC:

1. To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. P-R interval. d. QRS complex.

A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short. DIF: Cognitive Level: Understand (comprehension) REF: 791 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 12. Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 803 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 18. A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.

A The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate. DIF: Cognitive Level: Apply (application) REF: 801 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity OTHER 1. When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patient's chest. e. Check the location of other staff and call out "all clear."

A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff. DIF: Cognitive Level: Analyze (analysis) REF: 802 TOP: Nursing Process: Implementation MSC:

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

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

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

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

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

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

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

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

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

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

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

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

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

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

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

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

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

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

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

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

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

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

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

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

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

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

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

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

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

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

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

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

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

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

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

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

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

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

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

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

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

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

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

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

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

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

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

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

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

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

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

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

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

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

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

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

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

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

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

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

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

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

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

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

Physiological Integrity 16. A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6

B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area. DIF: Cognitive Level: Analyze (analysis) REF: 806 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.

B The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient. DIF: Cognitive Level: Apply (application) REF: 800 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 5. The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. 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/minute. DIF: Cognitive Level: Understand (comprehension) REF: 797 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.

C Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 28. A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 29. A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including oxygen saturation. d. Prepare to give a -blocker medication to slow the heart rate.

C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or -blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia. DIF: Cognitive Level: Analyze (analysis) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Monitor a patient's level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

C UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice. DIF: Cognitive Level: Analyze (analysis) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Physiological Integrity 15. When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.

D Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat). DIF: Cognitive Level: Apply (application) REF: 791 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

D 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 is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 17. Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L

D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

D The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Apply (application) REF: 794 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 7. A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

D 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 medication is started. 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. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

D The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered. DIF: Cognitive Level: Analyze (analysis) REF: 803 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Implementation MSC:

Physiological Integrity 19. A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

D The patient has progressive first-degree atrioventricular (AV) block, and the -blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic. DIF: Cognitive Level: Apply (application) REF: 798 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

D The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. DIF: Cognitive Level: Apply (application) REF: 804 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Psychosocial Integrity 11. After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a. "I will avoid cooking with a microwave oven or being near one in use." b. "It will be 1 month before I can take a bath or return to my usual activities." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side up very high until I see the doctor."

D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but 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. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Evaluation MSC: