UNIT 5 - CH27 PREPU with Rationales
A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). Which evaluation statement suggests that the client needs more instruction? "Client performs relaxation exercises three times per day to reduce stress." "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." "Client verbalizes an understanding of the need to seek emergency help if heart rate increases markedly while at rest." "Client walks 4 miles in 1 hour every day."
"Client walks 4 miles in 1 hour every day." Explanation: Four weeks after an MI, a client's walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises, following a low-fat, low-cholesterol diet, and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." "Client will verbalize the intention to avoid exercise." "Client will verbalize the intention to stop smoking." "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."
"Client will verbalize the intention to stop smoking." Explanation: A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse? "I should avoid taking a tub bath until my catheter site heals." "I should expect a low-grade fever and swelling at the site for the next week." "I should avoid prolonged sitting." "I should expect bruising at the catheter site for up to 3 weeks."
"I should expect a low-grade fever and swelling at the site for the next week." Explanation: Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.
When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions? "See if rest relieves the chest pain before using the nitroglycerin." "Call 911 if you develop a headache following nitroglycerin use." "Place the nitroglycerin tablet between cheek and gum." "Only take one nitroglycerin tablet for each episode of angina."
"See if rest relieves the chest pain before using the nitroglycerin." Explanation: Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. The client should expect to feel dizzy or flushed or to develop a headache following sublingual nitroglycerin use. The client should place one nitroglycerin tablet under the tongue if 2-3 minutes of rest fails to relieve pain. Clients may take up to three nitroglycerin tablets within 5 minutes of each other to relieve angina. However, they should call 911 if the three tablets fail to resolve the chest pain.
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? "The pain lasted about 45 minutes." "The pain resolved after I ate a sandwich." "The pain got worse when I took a deep breath." "The pain occurred while I was mowing the lawn."
"The pain occurred while I was mowing the lawn." Explanation: Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
A client is prescribed a nitroglycerin transdermal patch to treat angina. Which statement does the nurse include when reinforcing medication teaching to the client prior to discharge? "The medication patch causes headaches so you should remove it daily." "You do not need the effects of nitroglycerine while you sleep." "The patch should be worn for 12 hours and then removed for 12 hours." "Skin irritation is common when the patch is worn for more than 12 hours."
"The patch should be worn for 12 hours and then removed for 12 hours." Explanation: A transdermal nitroglycerin patch is prescribed for the prevention of angina pectoris. Nitroglycerin transdermal patches are typically applied for 12 to 14 hours, and then removed for the same amount of time. Though it is true that common adverse effects of nitroglycerin are headaches and contact dermatitis and that there is less demand on the heart when the client rests, these are not the reasons for applying and removing the patch for the same length of time in a 24-hour period.
A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding? "What color is your urine?" "Is your skin drier than normal?" "Do you have any breathing problems?" "How is your appetite?"
"What color is your urine?" Explanation: The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine. Anticoagulation therapy should not cause dry skin. The anticoagulation therapy should not change the client's breathing or appetite.
A client is receiving morphine to relieve chest pain. The order is for 4 mg IV now. The pharmacy supplies morphine sulfate at 5 mg per mL. How many mL will the nurse give the client? Enter the correct number ONLY.
0.8 Explanation: (4 mg/5 mg) X 1 mL = 0.8 mL.
The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication? 160-190 mg/dL 210-240 mg/dL 250-275 mg/dL 280-300 mg/dL
160-190 mg/dL Explanation: Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.
A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many milliliters per hour will the nurse infuse this solution? Record your answer using a whole number.
24 Explanation: (1200 units/25,000 units) X 500 mL = 24 mL.
A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse? 5 minutes 15 minutes 30 minutes 60 minutes
5 minutes Explanation: Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch). The nurse should instruct the client to take a second dose five minutes after the first if pain persists. The nurse should instruct the client to take a third dose five minutes after the second if pain still persists. The nurse should advise the client to call 911 if pressure or pain is not releived in 15 minutes by taking 3 tablets at 5-minute intervals
To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? 30 minutes 60 minutes 9 days 6 to 12 months
60 minutes Explanation: The 60-minute interval is known as "door-to-balloon time" in which to perform PTCA on a client diagnosed with MI. The 30-minute interval is known as "door-to-needle time" for administration of thrombolytics after MI. The time frame of 9 days = time until the onset of vasculitis (inflammation of blood vessels) after administration of streptokinase[thrombolytic] for thrombolysis in a client with an acute MI. The 6- to 12-month time frame refers to the time period during which streptokinase [thrombolytic] will not be used again in the same client for acute MI.
A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display? Fatty deposits in the lumen of arteries Cholesterol plugs in the lumen of veins Blood clots in the arteries Emboli in the veins
Fatty deposits in the lumen of arteries Explanation: Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.
A nurse reviews an ECG strip for a client who is admitted with symptoms of an acute MI. The nurse should recognize what classic ECG changes that occur with an MI? Select all that apply. Absent P-waves Abnormal Q-waves T-wave hyperactivity and inversions ST-segment elevations U-wave elevations
Abnormal Q-waves T-wave hyperactivity and inversions ST-segment elevations These three signs are classic ECG changes suggestive of a myocardial infarction. Changes can be diagnostic to the area of cellular damage. P wave and U wave changes are not characteristic of an MI.
A client recovering from percutaneous transluminal coronary angioplasty (PTCA) develops chest pain and an arrhythmia on the electrocardiogram (ECG). Which action(s) will the nurse take to help this client? Select all that apply. Administer oxygen Give meperidine as prescribed Obtain a 12-lead ECG Provide nitroglycerine Notify the primary healthcare provider
Administer oxygen Obtain a 12-lead ECG Provide nitroglycerine Notify the primary healthcare provider In percutaneous transluminal coronary angioplasty (PTCA), a balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia. It is used in clients with angina, and as an intervention for acute coronary syndrome (ACS). The purpose of PTCA is to improve blood flow within a coronary artery by compressing the atheroma. A client who develops chest pain and a cardiac arrhythmia might be experiencing a MI caused by thrombosis or restenosis of a coronary artery. Actions that the nurse should take include: - administering oxygen, -obtaining a 12-lead ECG, -providing nitroglycerin, -and notifying the cardiologist. Meperidine is not identified as an action to take if a client demonstrates signs of a myocardial infarction after a PTCA. Oxygen is placed to decrease workload of the heart and to perfuse the blood with supplemental oxygen, decreasing the severity of the tissue ischemia. A 12-lead ECG is ordered to monitor heart rhythms. Nitroglycerin is provided as a vasodilator to increase tissue perfusing and to decrease anginal chest pain. The cardiologist should be notified as there is likely a complication of the procedure.
A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse? Altered level of consciousness Minimal oozing of blood from the IV site Presence of reperfusion dysrhythmias Chest pain 2 of 10 (on a 1-to-10 pain scale)
Altered level of consciousness Explanation: A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client's chest pain is subsiding, an expected outcome of this therapy.
The nurse is administering oral metoprolol. Where are the receptor sites mainly located? Uterus Blood vessels Bronchi Heart
Heart Explanation: Metoprolol works at beta 1 -receptor sites. Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.
The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply. Place pillows in the popliteal space. Apply antiembolism stockings. Encourage the client to cross their legs. Avoid elevating the knees on the bed. Initiate passive exercises.
Apply antiembolism stockings. Avoid elevating the knees on the bed. Initiate passive exercises. Preventive measures used to prevent venous stasis include: - application of sequential pneumatic compression devices; - discouraging crossing of legs; - avoiding elevating the knees on the bed; - omitting pillows in the popliteal space; and - beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.
An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take? Educate the family about how confusion is expected in older adults postoperatively. Assess for factors that may be causing the client's delirium. Document the early signs of dementia and ensure the client's safety. Reorient the client to place and time.
Assess for factors that may be causing the client's delirium. Explanation: Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? Assess the client's mental and emotional status. Assess the skin of the client. Assess the characteristics of chest pain. Assess for any kind of drug abuse.
Assess the characteristics of chest pain. Explanation: The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart
A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse? Central venous pressure reading of 1 Pain score 5/10 Blood pressure 110/68 mm Hg Heart rate 66 bpm
Central venous pressure reading of 1 Explanation: The central venous pressure (CVP) reading of 1 is low (2-6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.
The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply. Balance rest with activity. Stop smoking. Avoid all physical activity. Carry nitroglycerin at all times. Follow a diet high in saturated fats.
Balance rest with activity. Stop smoking. Carry nitroglycerin at all times. Managing angina pectoris at home includes balancing rest with activity, participating in a regular daily program of activities that do not induce angina pain, stopping smoking, carrying nitroglycerin at all times, and following a diet low in saturated fat.
Which is a diagnostic marker for inflammation of vascular endothelium? C-reactive protein (CRP) Low-density lipoprotein (LDL) High-density lipoprotein (HDL) Triglyceride
C-reactive protein (CRP) Explanation: CRP is a marker for inflammation of the vascular endothelium. Elements of fat metabolism= LDL, HDL, and triglycerides; they are not markers of vascular endothelial inflammation.
The nurse is assisting with a bronchoscopy at the bedside in a critical care unit. The client experiences a vasovagal response. What should the nurse do next? Prepare to administer intravenous fluids. Suction the airway. Check blood pressure. Assess pupils for reactiveness.
Check blood pressure. Explanation: During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it in turn may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate, leading to syncope. The nurse will need to assess blood pressure to assure circulation. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.
A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? Chest discomfort not relieved by rest or nitroglycerin Intermittent nausea and emesis for 3 days Cool, clammy skin and a diaphoretic, pale appearance Anxiousness, restlessness, and lightheadedness
Chest discomfort not relieved by rest or nitroglycerin Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.
A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent? Clopidogrel Isosorbide mononitrate Metoprolol Diltiazem
Clopidogrel Explanation: Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.
A client comes to the emergency department (ED) reporting precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client? Coronary artery disease Raynaud syndrome Cardiogenic shock Venous occlusive disease
Coronary artery disease Explanation: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be - centered over the heart (precordial) or - under the sternum (substernal). Raynaud syndrome in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.
A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect? Decreases resting heart rate Decreases cholesterol level Increases cardiac output Decreases platelet aggregation
Decreases resting heart rate Explanation: The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. In general, the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.
The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD? Cholesterol, 280 mg/dL Low density lipoprotein (LDL), 160 mg/dL High-density lipoprotein (HDL), 80 mg/dL A ratio of LDL to HDL, 4.5 to 1.0
High-density lipoprotein (HDL), 80 mg/dL Explanation: A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.
When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality? Hypercalcemia Hyperkalemia Hypomagnesemia Hyponatremia
Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia asystole= flat line: no CO Hypomagnesemia : hypotension, lethargy, and vasodilation. Hyponatremia : weakness, fatigue, and confusion, without a change in T wave formation
Which of the following is inconsistent as a condition related to metabolic syndrome? Hypotension Insulin resistance Abdominal obesity Dyslipidemia
Hypotension Explanation: A diagnosis of metabolic syndrome includes three of the following conditions: - insulin resistance, - abdominal obesity, - dyslipidemia, - hypertension, -proinflammatory state, - prothrombotic state.
A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload? IV morphine IV nitroglycerin Atenolol Amlodipine
IV morphine Explanation: IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of atenolol and amlodipine are not indicated in this situation.
When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition? Inadequate fluid volume Normal glomerular filtration Overhydration Anuria
Inadequate fluid volume Explanation: Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.
The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.) It is relieved by rest and inactivity. It is substernal in location. It is sudden in onset and prolonged in duration. It is viselike and radiates to the shoulders and arms. It subsides after taking nitroglycerin.
It is substernal in location. It is sudden in onset and prolonged in duration. It is viselike and radiates to the shoulders and arms. Explanation: Chest pain that occurs suddenly, continues despite rest and medication, is substernal, and is sometimes viselike and radiating to the shoulders and arms is associated with an MI. Angina pectoris pain is generally relieved by rest and nitroglycerin.
Which technique is used to surgically revascularize the myocardium? Balloon bypass Peripheral bypass Minimally invasive direct coronary bypass Gastric bypass
Minimally invasive direct coronary bypass Explanation: Several techniques are used to surgically revascularize the myocardium; one of them is minimally invasive direct coronary bypass. Balloon bypass is not used to revascularize the myocardium. If the client is experiencing acute pain in the leg, peripheral bypass is performed. Gastric bypass is a surgical procedure that alters the process of digestion.
Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? Cleanse the site with disinfectants and dress the wound appropriately Refrain from sexual activity for 1 month Monitor the site for bleeding or hematoma. Normal activities of daily living can be resumed the first day after surgery
Monitor the site for bleeding or hematoma. Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? Isosorbide mononitrate (Isordil) Meperidine hydrochloride (Demerol) Morphine sulfate (Morphine) Nitroglycerin transdermal patch
Morphine sulfate (Morphine) Explanation: Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease HR, BP, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina-type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.
A client presents to the ED reporting anxiety and chest pain after shoveling heavy snow that morning. The client says that nitroglycerin has not been taken for months but upon experiencing this chest pain did take three nitroglycerin tablets. Although the pain has lessened, the client states, "They did not work all that well." The client shows the nurse the nitroglycerin bottle; the prescription was filled 12 months ago. The nurse anticipates which order by the physician? Nitroglycerin SL Chest x-ray Serum electrolytes Ativan 1 mg orally
Nitroglycerin SL Explanation: Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired, and the nurse should anticipate administering nitroglycerin to assess whether the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the client's chest pain.
The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received? Protamine sulfate Alteplase Clopidogrel Aspirin
Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.
A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation? Prothrombin time (PT) or international normalized ratio (INR) Hourly IV infusion Vascular sites for bleeding Urine output
Prothrombin time (PT) or international normalized ratio (INR) Explanation: The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.
A client reports chest pain that occurs when playing tennis but resolves when sitting down. The nurse knows these symptoms are common for which type of angina? Stable Variant Unstable Intractable
Stable Explanation: Angina is usually caused by atherosclerotic disease and most often is associated with a significant obstruction of at least one major coronary artery. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When demand increases, flow through the coronary arteries needs to be increased. When there is a blockage in a coronary artery, flow cannot be increased and ischemia results. There are different types of angina. Stable angina is predictable and consistent pain that occurs on exertion and is relieved by rest or nitroglycerin. This is the type of angina the client is describing. Variant angina is pain at rest with reversible ST-segment elevation and is thought to be caused by a spasm of a coronary artery. In unstable angina, the symptoms increase in frequency and severity and may not be relieved with rest or nitroglycerin. Intractable angina pectoris causes severe incapacitating chest pain.
The client is prescribed nadolol for hypertension. What is the reason the nurse will teach the client not to stop taking the medication abruptly? The abrupt stop can cause a myocardial infarction. The abrupt stop can lead to formation of blood clots. The abrupt stop will precipitate internal bleeding. The abrupt stop can trigger a migraine headache.
The abrupt stop can cause a myocardial infarction. Explanation: Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or the onset of a migraine headache.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client demonstrates ability to tolerate more activity without chest pain. The client exhibits a heart rate above 100 beats/minute. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. The client states that sublingual nitroglycerin usually relieves his chest pain.
The client demonstrates ability to tolerate more activity without chest pain. Explanation: The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.
A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)? The patient has compromised left ventricular function. The patient has had angina longer than 3 years. The patient has at least a 70% occlusion of a major coronary artery. The patient has an ejection fraction of 65%.
The patient has at least a 70% occlusion of a major coronary artery. Explanation: For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? To dilate coronary arteries To decrease workload of the heart To decrease homocysteine levels To prevent angiotensin II conversion
To decrease workload of the heart Explanation: Beta-adrenergic blockers are used in the treatment of CAD to decrease the consumption of myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.
The nurse knows that women and older adult are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause? Chest pain is typical Vague symptoms Decreased sensation to pain Gender bias
Vague symptoms Explanation: Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? Inform client of diagnostic tests. Remove hair from skin insertion sites. Assess distal pulses. Withhold anticoagulant therapy.
Withhold anticoagulant therapy. Explanation: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain? incomplete blockage of a major coronary artery a destroyed part of the heart muscle complete closure of an artery a lack of oxygen in the heart muscle cells
a lack of oxygen in the heart muscle cells Explanation: Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction.
The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low-density lipoprotein (LDL) level is 112 mg/dL. The nurse recognizes that this value is below the optimal range. above the optimal range. within the optimal range. extremely high.
above the optimal range. Explanation: If the fasting LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered above the optimal range. The ideal is to decrease the LDL level below 100 mg/dL (< 70 mg/dL for very high-risk patients).
A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? calcium-channel blocker beta-adrenergic blocker nitrate diuretic
calcium-channel blocker Explanation: Calcium-channel blocking agents may be used to treat CAD as well, although research has shown that they may be less beneficial than beta-adrenergic blocking agents. Diltiazem (Cardizem) is an example of a calcium-channel blocker.
A client who has been diagnosed with Prinzmetal's angina will present with which symptom? chest pain that occurs at rest and usually in the middle of the night radiating chest pain that lasts 15 minutes or less prolonged chest pain that accompanies exercise chest pain of increased frequency, severity, and duration
chest pain that occurs at rest and usually in the middle of the night Explanation: A client with Prinzmetal's angina will complain of chest pain that occurs at rest, usually between 12 and 8:00 AM, is sporadic over 3-6 months, and diminishes over time. Clients with stable angina generally experience chest pain that lasts 15 minutes or less and may radiate. Clients with Cardiac Syndrome X experience prolonged chest pain that accompanies exercise and is not always relieved by medication. Clients with unstable angina experience chest pain of increased frequency, severity, and duration that is poorly relieved by rest or oral nitrates.
A client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows: elevated troponin levels. decreased LDH levels. decreased myoglobin levels. increased C-reactive protein levels.
elevated troponin levels. Explanation: Troponin is present only in myocardial tissue; therefore, it is the gold standard for determining heart damage in the early stages of an MI. LDH1 & LDH2 may be elevated in response to cardiac or other organ damage during an MI. Myoglobin is a biomarker that rises in 2 - 3 hours after heart damage during an MI. The levels below would not be elevated during the MI event, ONLY on ~ 3rd day C-reactive protein, (CRP) erythrocyte sedimentation rate, ESR and the WBC count increase on about the third day following MI because of the inflammatory response that the injured myocardial cells triggered.
The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? decrease anxiety enhance myocardial oxygenation administer sublingual nitroglycerin educate the client about his symptoms
enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.
The nurse is teaching a client about atherosclerosis. The client asks the nurse what the substance causing atherosclerosis is made of. How does the nurse best respond? fatty deposits in the lumen of arteries cholesterol plugs in the lumen of veins blood clots in the arteries emboli in the veins
fatty deposits in the lumen of arteries Explanation: Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. The plaque does not involve blood clots in arteries, emboli in veins or cholesterol plugs in veins.
A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? blood pressure of 129/72 mm Hg heart rate of 87 bpm hemoglobin of 16 g/dL hematocrit of 30%
hematocrit of 30% Explanation: Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.
A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a: high LDL level. low LDL level. normal LDL level. fasting LDL level.
high LDL level. Explanation: LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.
The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as high. low. within normal limits. critically high.
high. Explanation: Treatment of blood cholesterol to reduce cardiovascular risk in adults calls for a fasting lipid profile to demonstrate an LDL value below 100 mg/dL (or less than 70 mg/dL for very high-risk clients). An LDL level of 115 mg/dL is higher than the target for treatment.
The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with percutaneous coronary intervention (PCI). IV heparin. IV nitroglycerin. thrombolytics.
percutaneous coronary intervention (PCI). Explanation: The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.
The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome? pericardial friction rub hypothermia decreased white blood cell (WBC) count decreased erythrocyte sedimentation rate (ESR)
pericardial friction rub Explanation: Post-pericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of post-pericardiotomy syndrome.
