Acute Coronary Syndrome (ACS) EAQ

In which order would the nurse arrange the sequence of actions that occur during coronary artery bypass graft (CABG) surgery?

1. A median sternotomy incision is made, and the heart and great vessels are visualized. 2. The heart is arrested using the bypass machine. 3. The radial artery is used to bypass blockages. 4. The radial artery is anastomosed proximally to the aorta. 5. The vessel graft is dissected and attached below the clot. 6. The heart is weaned from the bypass machine. The sequence of actions of CABG surgery begins with a median sternotomy incision and visualization of the heart and great vessels. The heart is then arrested using a bypass machine. The radial artery is used to bypass blockages. It is anastomosed proximally to the aorta; the distal end is dissected and attached below the clot. Finally, the heart is weaned from the bypass machine, and the patient begins recovery. Nurses should learn the basics about medical and surgical procedures that are relevant to their nursing practice to better anticipate potential patient complications and the need for specific nursing interventions.

A patient weighing 165 lb reports having chest discomfort for the past 50 minutes. Subcutaneous administration of low-molecular-weight heparin (LMWH) was prescribed followed by the administration of IV heparin. Which dose of heparin would the nurse administer?

75 mg The dosage of LMWH is based on the weight of the patient (1 mg/kg); 165 lb is equal to 75 kg, so the dosage of LMWH for a patient weighing 165 lb is 75 mg.

Which instruction would the nurse give to a patient with coronary artery disease after surgical intervention? Select all that apply. A. "Avoid straining activities." B. "Avoid carrying nitroglycerin with you." C. "Avoid outdoor exercise when the weather is good." D. "Avoid checking your pulse before and after exercise." E. "Avoid exercising when your pulse increases more than 20 beats/min."

A. "Avoid straining activities." E. "Avoid exercising when your pulse increases more than 20 beats/min." Straining activities like lifting and pushups may make the sternum's healing process worse. Stopping exercise when the pulse increases to more than 20 beats/min will decrease the risk for injury and fatigue. Nitroglycerin is used in case of emergency (sudden rise in blood pressure) and should be carried by the patient. Outdoor exercise in good weather is refreshing. A patient's pulse should be checked before exercise, and if the pulse rate is higher than it should be, the patient should stop exercising. After exercise, the patient's pulse should be checked to avoid any complications such as shortness of breath and dizziness.

Which statement about the coronary artery bypass grafting (CABG) procedure indicates a need for further teaching? A. "Best outcomes from CABG occur when coronary arteries have less than a 50% occlusion." B. "CABG may be used when the left main coronary artery is occluded and a stent cannot be placed." C. "The quality of the patient's life will be improved by CABG surgery." D. "Best long-term graft patency results when the internal mammary artery is used."

A. "Best outcomes from CABG occur when coronary arteries have less than a 50% occlusion." In CABG, the vessels to be bypassed typically have 50% or more of the vessel blocked; bypassing vessels with lesser occlusion may result in early obstruction. CABG is used for left main coronary artery disease that is not amenable to stent placement. Quality of life rather than life span is improved with CABG. Ninety percent of internal mammary artery grafts remain patent for 12 years.

After an initial assessment of a patient with chest pain, tightness, and shortness of breath, the nurse suspects the patient has acute coronary syndrome (ACS). Which would the nurse expect the health care provider to do immediately based on the recommendations provided by the American Heart Association (AHA)? A. Administer morphine sulfate to the patient. B. Initiate cardiopulmonary resuscitation (CPR). C. Administer nitroglycerin (NTG) tablets sublingually. D. Place the patient in a semi-Fowler position.

A. Administer morphine sulfate to the patient. According to the AHA, if a patient is suspected of having ACS, morphine sulphate should be administered immediately. CPR is required only when a patient needs to be revived. The AHA does not recommend NTG tablets for ACS; however, the patient can take this medication sublingually to get relief from chest pain. Placing the patient in semi-Fowler position can increase comfort and tissue oxygenation; however, this is not the priority action.

Which finding acquired during an annual physical examination would lead the nurse to focus on health promotion, including ways to decrease risks for developing coronary artery disease (CAD)? Select all that apply. A. Blood pressure B. Total cholesterol C. Cigarette smoking D. Sedentary lifestyle E. Height-to-weight ratio

A. Blood pressure B. Total cholesterol C. Cigarette smoking D. Sedentary lifestyle E. Height-to-weight ratio The nurse would identify that the patient presents with high blood pressure and elevated total cholesterol as well as smoking one pack of cigarettes per day, leads a sedentary lifestyle, and is overweight. These are all risk factors for CAD, which would lead the nurse to address this with the patient.

Which action would a patient take if he or she has new-onset angina at home? A. Ingest four low-dose aspirins 81 mg each. B. Ingest three low-dose aspirins 85 mg each. C. Ingest four low-dose aspirins 85 mg each. D. Ingest three baby aspirins 81 mg each.

A. Ingest four low-dose aspirins 81 mg each. A patient with new-onset angina at home is advised to chew 325 mg of aspirin, or four baby aspirins, 81 mg each, immediately and then call 911. Ingesting four baby aspirins 85 mg each, three baby aspirins 81 mg each, and three baby aspirins 85 mg each do not meet the recommended dose requirements.

The nurse is caring for a patient admitted to the telemetry floor for possible myocardial infarction (MI). Which action would the nurse take when administering sublingual nitroglycerin to the patient? Select all that apply. A. Monitor blood pressure. B. Monitor the patient for dizziness. C. Monitor the patient for a headache. D. Administer with the patient lying down. E. Administer every 5 minutes up to three times.

A. Monitor blood pressure. B. Monitor the patient for dizziness. C. Monitor the patient for a headache. D. Administer with the patient lying down. E. Administer every 5 minutes up to three times. Nitroglycerin increases perfusion to the coronary arteries through perfusion; however, the vasodilation is generalized and may cause hypotension, dizziness, and a headache. Nitroglycerin should be administered with the patient lying down to prevent a fall from hypotension or dizziness. Sublingual nitroglycerin may be administered once every 5 minutes up to three times if the pain is not relieved with the first dose.

When planning care for a patient in the emergency department, the nurse understands that which intervention is needed in the acute phase of myocardial infarction (MI)? Select all that apply. A. Morphine sulfate B. Oxygen C. Nitroglycerin D. Naloxone E. Acetaminophen F. Verapamil

A. Morphine sulfate B. Oxygen C. Nitroglycerin Morphine is needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers like verapamil are used for angina, not for MI.

Which intervention would the nurse anticipate will be prescribed for a patient who has sustained an ST-segment myocardial infarction (STEMI) to the anterior wall and new-onset third-degree heart block? A. Pacemaker B. Defibrillation C. Cardioversion D. Heparin infusion

A. Pacemaker Third-degree heart block is a complication of a large myocardial infarction (MI) resulting in profound bradycardia; a pacemaker is indicated to restore hemodynamic stability. Defibrillation is indicated in patients with ventricular fibrillation or pulseless ventricular tachycardia. Cardioversion (synchronized electrical energy directed to the heart) is used to correct rapid rhythms such as atrial fibrillation, atrial flutter, or supraventricular tachycardia. Heparin infusion is used in patients with MI to maintain the patency of the coronary artery after thrombolysis or in acute coronary syndrome.

Which manifestation would indicate the presence of postpericardiotomy syndrome in the patient who had coronary artery bypass graft (CABG) surgery? Select all that apply. A. Pericardial and pleural pain B. Cardiac dysrhythmias C. Reduced white blood cell count D. Bogginess of tissue above the sternum E. Fever lasting more than 4 days after surgery

A. Pericardial and pleural pain B. Cardiac dysrhythmias Pleural pain and cardiac dysrhythmias are the manifestations of postpericardiotomy syndrome, which may be caused by blood remaining in the pericardial sac after the surgery. An increase in white blood cell count is a manifestation of postpericardiotomy syndrome. A sternum that feels mushy on palpation and a fever that continues beyond the first 4 days after CABG surgery are manifestations of mediastinitis—an infection of the mediastinum.

Which finding indicates the patient with coronary artery disease has had an acute myocardial infarction (MI)? A. Q wave noted on ECG B. Normal ECG with chest pain C. ST elevation in all precordial leads D. ST-segment depression during chest pain

A. Q wave noted on ECG Evolution of an ST-elevation myocardial infarction (STEMI) begins with ST-segment elevation in leads corresponding to the damaged wall of the heart, followed by T-wave inversion and a permanent Q wave. An ECG of an MI will not show as normal. STsegment elevation in all leads may be present in pericarditis. ST-segment depression with chest pain is typical in angina.

Which disadvantage of robotic surgery would the nurse provide to a patient who has coronary artery disease (CAD)? A. Surgery time is longer. B. Hospital stay is increased. C. Postoperative pain is increased. D. The ability to reach that are difficult to reach is reduced.

A. Surgery time is longer. One of the disadvantages of robotic heart surgery is that it increases the time of surgery by about 50 minutes compared with conventional surgery. The advantages of robotic heart surgery are shorter hospital stays and less pain for the patient because the procedure uses very small incisions in the chest wall. Robotic heart surgery also increases, not reduces, the ability to reach sites that are difficult to reach.

Which medication would the nurse assess the patient for before administering nitroglycerin for chest pain? Select all that apply. A. Tadalafil B. Cardizem C. Sildenafil D. Carvedilol E. Metoprolol

A. Tadalafil C. Sildenafil Tadalafil and sildenafil are phosphodiesterase inhibitors used for treatment of erectile dysfunction. When given with nitroglycerin, they can cause profound hypotension. Cardizem, carvedilol, and metoprolol are not contraindicated with administration of nitroglycerin.

Which principle related to angina pain is important for the nurse to remember? A. The administration of nitroglycerin (NTG) will improve oxygen supply. B. There will be an ST elevation noted on the ECG. C. The patient will have an increase in body temperature. D. Premature ventricular contractions (PVCs) accompany the pain.

A. The administration of nitroglycerin (NTG) will improve oxygen supply. The pain of angina is typically relieved by NTG, which increases the oxygen supply to cardiac tissues. An ST elevation noted on the rhythm of an ECG signifies a myocardial infarction (MI); there are no rhythm changes with angina. An elevation in body temperature occurs for several days after a patient experiences an MI. PVCs occur within the first few hours after a patient experiences an MI.

Which conclusion would the nurse draw for a patient diagnosed with coronary artery disease (CAD) who is prescribed metoprolol and reports weight gain, cough, shortness of breath, and swelling in the legs? A. The patient has developed heart failure. B. The patient has developed metabolic syndrome. C. The patient needs naloxone administration. D. The patient needs dobutamine administration.

A. The patient has developed heart failure. Metoprolol is a cardio-selective beta-adrenergic blocker used to treat CAD. Metoprolol may depress myocardial contractility, resulting in heart failure. Cough, shortness of breath, edema, and weight gain are symptoms of heart failure. High blood pressure, obesity, decreased high-density lipoprotein cholesterol, and increased triglycerides are symptoms of metabolic syndrome. Naloxone is a drug used to reverse the adverse effects that are associated with the administration of opioids, such as morphine. Dobutamine is administered during stress testing.

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

A. The patient with acute coronary syndrome who has a 3-lb weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this patient needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the patient with dyspnea is taken care of. The patient with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the patient has a normal heart rate; the patient with dyspnea should be seen first.

The nurse is evaluating the outcomes for a patient admitted 2 days ago after sustaining an ST-elevation myocardial infarction (STEMI) who underwent a cardiac catheterization with stent placements. Which finding indicates the patient is stabilizing? Select all that apply. A. Troponin level 0.34 ng/mL B. ST elevation in 12-lead C. ECG Blood pressure 153/87 mmHg D. Oxygen saturation 90% on room air E. Minimal chest pain with ambulation

A. Troponin level 0.34 ng/mL The patient's troponin level is within normal limits, which indicates the patient is stabilizing. The patient still has an ST elevation in the ECG, which is what happens when a patient has a STEMI and does not reflect improvement. The blood pressure of 153/87 mmHg is elevated, and the oxygen saturation is decreased. Both of these findings indicate the patient needs further treatment because of unstable cardiovascular status. The patient should have no chest pain after having stents placed.

Which finding during administration of tissue plasminogen activator (tPA) causes the nurse to notify the health care provider immediately? A. Unilateral facial drooping B. ST-segment elevation on the ECG C. Blood backing up in the IV tubing D. Patient with menses saturates four perineal pads in a 12-hour shift

A. Unilateral facial drooping tPA is a thrombolytic medication that dissolves thrombi in the coronary arteries; the major side effect is bleeding as clots are lysed. Facial droop may be symptomatic of a stroke caused by intracerebral hemorrhage, and the nurse should immediately contact the health care provider. Resolution of ST-segment elevation should occur when administering tPA. Blood may back up in IV tubing for many reasons, including positioning of the IV catheter relative to the medication; this can easily be fixed by determining the underlying cause. Heavy menses is expected with anticoagulant therapy and thrombolytic therapy, although hemorrhage should be reported to the health care provider.

When assessing a patient with evolving myocardial infarction (MI), the nurse would be alert for which associated symptom? A. Vomiting B. Leg pain C. Depression D. S1 heart sound

A. Vomiting In addition to chest pain, patients sustaining an MI may also display dyspnea; ashen, cool, and clammy skin; diaphoresis; nausea, vomiting or epigastric pain; anxiety; and a feeling of impending doom or dizziness. Leg pain may occur with fracture or deep vein thrombosis. Denial is the typical response to MI; depression may occur after an MI. An S1 heart sound or "lub" should be present at all times.

Which drug is a beta blocker used to treat coronary artery disease (CAD)? A. Aspirin B. Carvedilol C. Clopidogrel D. Prasugrel

B. Carvedilol Carvedilol is a beta blocker used to treat CAD. It decreases the size of the infarct and the occurrence of ventricular dysrhythmias. Aspirin is an antiplatelet agent used to treat CAD that inhibits platelet aggregation and vasoconstriction and decreases the occurrence of thrombosis. Clopidogrel and prasugrel are thienopyridines that prevent platelet aggregation, slowing the rate of clot formation, and they are also used in the treatment of CAD.

Which patient activity best reflects the goal of phase 3 cardiac rehabilitation? A. Beginning a weightlifting program B. Developing a plan to walk briskly for physical conditioning C. Resting and possibly ambulating short distances three times daily D. Returning home and convalescing from the myocardial infarction

B. Developing a plan to walk briskly for physical conditioning Three phases of cardiac rehabilitation exist. Phase 1 begins with the acute illness and ends with discharge from the hospital. Resting along with short distance ambulation is a phase 1 goal. Phase 2 begins after discharge and continues through convalescence at home. Phase 3 refers to long-term conditioning. This would include developing a plan for brisk walking as daily physical conditioning. Weightlifting is not a recommended activity because the patient often holds the breath and performs the Valsalva maneuver while lifting, which can cause bradycardia.

Which drug is an inotrope that may be used to maintain organ perfusion in a patient who had heart failure after a myocardial infarction (MI)? A. Nitroglycerin (NTG) B. Dobutamine C. Fenoldopam D. Milrinone

B. Dobutamine Dobutamine is an inotrope that may be used to maintain organ perfusion in a patient who sustained heart failure after an MI. Dobutamine increases the force of cardiac contraction. NTG and fenoldopam are nitrates that are used to maintain organ perfusion. Nitrates cause vasodilation of arteries and veins. Milrinone is also an inotrope, but it is also classified as a nitrate because of its vasodilation effects.

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

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

Which action would the nurse perform when caring for a patient with coronary artery disease (CAD) who has been prescribed metoprolol XR? A. Instruct the patient to not take sildenafil with this medication. B. Hold the medication if the heart rate is less than 50 to 60 beats/min. C. The medication can be crushed and mixed with pudding. D. Teach the patient to lie down on the bed 30 minutes after administration.

B. Hold the medication if the heart rate is less than 50 to 60 beats/min. The nurse should not administer metoprolol if the patient's heart rate is less than 50 to 60 beats/min because it is a beta blocker. A side effect of beta blockers is bradycardia, and this medication would further decrease the heart rate. Beta blockers are safe to take with sildenafil. Nitrates are not administered with sildenafil because fatal interactions occur between these drugs. Metoprolol XR is an extended-release medication and cannot be crushed; the capsule must be taken whole. Patients taking nitrates, not beta blockers, are taught to lie down on the bed after administration because an upright position intensifies hypotension, which can be fatal.

Which immediate action would the nurse take when a patient presents to the emergency department with chest pain? A. Obtain a chest x-ray. B. Obtain a 12-lead ECG. C. Obtain an 18-lead ECG. D. Obtain troponins T and I.

B. Obtain a 12-lead ECG. When a patient presents with chest pain, national guidelines recommend that an initial ECG be obtained within the first 10 minutes of arrival to the emergency department. A chest x-ray may be performed to help rule out aortic dissection, which may mimic a myocardial infarction (MI) but it is not done immediately. An 18-lead ECG or "right-sided" ECG is typically performed to rule out a right-sided MI. Obtaining laboratory tests such as troponin is important but is not performed immediately.

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

B. Obtains the patient's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Pain medication and oxygen therapy are not the first priority in this situation; an assessment is needed first. Remaining calm and staying with the patient is important, but this is not the matter of highest priority.

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

B. Pain relief improves oxygen supply and decreases oxygen demand. The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, it does not relate to MI.

Which patient who had a myocardial infarction would the nurse see first? A. Patient with dyspnea on exertion when ambulating to the bathroom B. Patient with third-degree heart block on the monitor C. Patient with normal sinus rhythm and PR interval of 0.28 seconds D. Patient who refuses to take heparin or nitroglycerin

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

Which side effect would the nurse monitor for when caring for a patient with coronary artery disease (CAD) who is prescribed carvedilol? A. Risk for bleeding B. Shortness of breath C. Ringing in the ears D. Gastric irritation

B. Shortness of breath Carvedilol is a beta blocker that usually causes bronchoconstriction. Shortness of breath is most likely to be observed in a patient taking the drug. Patients taking thienopyridines or antiplatelet agents are at risk for bleeding. These drugs prevent platelet aggregation and slow clot formation. Patients taking aspirin may experience ringing in the ears because of aspirin toxicity. Aspirin can also cause gastric irritation if taken on an empty stomach.

Which sign indicates that the patient who received tissue plasminogen activator (tPA) has had a positive outcome with successful reperfusion? A. A Q wave develops on the 12-lead ECG. B. The monitor shows episodes of ventricular tachycardia. C. ST-segment depression goes from 1 to 3 mm. D. The patient's heart rate goes from 110 beats/min to 58 beats/min.

B. The monitor shows episodes of ventricular tachycardia. Administration of tPA, a thrombolytic, should result in the successful outcome of increased coronary artery reperfusion. Evidence of reperfusion includes cessation of chest pain, sudden onset of ventricular dysrhythmia, or resolution of ST-segment depression/elevation or T-wave inversion. A Q wave on the ECG indicates tissue necrosis; the Q wave is reflected when necrotic cells do not conduct electrical stimuli. ST-segment depression going from 1 to 3 mm demonstrates worsening ischemia rather than reperfusion. Sinus bradycardia is not a ventricular dysrhythmia; rather the impulse for this rhythm initiates in the sinus node located in the right atrium.

Which finding in a patient after cardiopulmonary bypass surgery causes the nurse to intervene immediately? A. The patient's magnesium level is 2.2 mEq/L. B. The patient's temperature is 96.2°F (35.7°C). C. The patient's blood pressure is 117/76 mm Hg. D. The patient has a potassium level of 4.0 mEq/

B. The patient's temperature is 96.2°F (35.7°C). The nurse prioritizes care for the patient by addressing the temperature finding. A body temperature of 96.2°F (35.7°C) indicates hypothermia, which can occur after cardiopulmonary bypass surgery. The nurse needs to institute rewarming procedures and monitor the temperature rise of the patient so that the patient is warmed safely. The magnesium level of 2.2 mEq/L is a desired finding. A blood pressure of 117/76 mm Hg is not indicative of hypertension or hypotension, both of which the nurse must monitor in the postoperative patient. The potassium level of 4.0 mEq/L is a desired finding.

When administering morphine sulfate to a patient with a myocardial infarction, the nurse observes for which adverse effect? Select all that apply. A. Chest pain B. Vomiting C. Sinus tachycardia D. Respiratory depression E. Hypertension

B. Vomiting D. Respiratory depression Morphine sulfate is used to relieve chest pain by reducing myocardial oxygen demand secondary to peripheral vasodilation; adverse effects include bradycardia (rather than tachycardia), respiratory depression, vomiting, and hypotension (rather than hypertension). Morphine is used to treat the chest pain; chest pain itself is not a side effect.

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

C. "These arteries remain open longer." Mammary arteries remain patent much longer than other grafts. Although no leg incision would be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

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

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

Which is the most suitable body temperature for cardiopulmonary bypass? A. 90°F (32.2°C) B. 95°F (35°C) C. 96°F (35.5°C) D. 102°F (38.8°C)

C. 96°F (35.5°C) During cardiopulmonary bypass, the body temperature should be between 95°F and 98°F (35°C and 36.6°C), so 96°F is the most suitable body temperature during bypass from the options provided. Although cooling decreases the rate of metabolism and demand for oxygen, keeping the heart "warm" decreases the postoperative complications that are more common when cold cardioplegia is used. Temperatures below 95°F (35°C) and above 98°F (36.6°C) may increase the amount of postoperative complications, so 90°F, 95°F, and 102°F (32.2°C, 35°C, and 38.8°C) are not suitable temperature options for cardiopulmonary bypass.

Which action would the nurse take for an older-adult patient 4 hours after coronary artery bypass graft (CABG) surgery who has a blood pressure of 80/50 mm Hg? A. No action is required; low blood pressure is normal for older adults. B. No action is required for postsurgical CABG patients. C. Assess pulmonary artery wedge pressure (PAWP). D. Give prescribed loop diuretics.

C. Assess pulmonary artery wedge pressure (PAWP). Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative patients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.

A patient has undergone percutaneous coronary intervention (PCI) through the right femoral artery and has received a bivalirudin infusion during the procedure. Which action is the nurse's priority when the patient returns? A. Monitor the urine output. B. Observe the patient for cough. C. Monitor the insertion site for bleeding. D. Question the patient about pain in the groin.

C. Monitor the insertion site for bleeding. Bivalirudin is a direct thrombin inhibitor used during PCI; by inhibiting thrombin, bleeding may occur. Cough may be a symptom of heart failure, but it is not a specific complication of the PCI. The urine output should be monitored as contrast is used during PCI, but observing for hemorrhage is the priority. A local anesthetic is used during PCI, and pain may indicate hematoma; however, observation for bleeding is essential as a large artery is entered for this procedure and anticoagulation is used.

Which suggestion would the nurse make for a patient in phase 1 cardiac rehabilitation? A. Increasing activities slowly at home B. Planning and participating in a walking program C. Placing a chair in the shower for independent hygiene D. Consulting with a social worker for disability planning

C. Placing a chair in the shower for independent hygiene Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing patients to improve their ADLs based on their abilities. This would include placing a chair in the shower for independent hygiene. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning; it consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

A patient diagnosed with evolving myocardial infarction abruptly develops ventricular fibrillation. Which is the priority action for the nurse at this time? A. Monitor the ECG. B. Administer nitroglycerin. C. Provide defibrillation. D. Administer oxygen.

C. Provide defibrillation. The priority for ventricular fibrillation is immediate defibrillation; the patient is apneic, pulseless, and breathless secondary to chaotic and ineffective heart rhythm, and this must be terminated with immediate electrical shock. Monitoring the ECG delays the required defibrillation and restoration of cardiac output. Although nitroglycerin is used for myocardial infarction, it has no antidysrhythmic property and will not terminate ventricular fibrillation. Because the patient with ventricular fibrillation is apneic, administering oxygen will be of no use.

Which statement by the nurse is most important for a patient experiencing a myocardial infarction who is upset and tells the nurse he or she is afraid of dying? A. "I am not going to let you die." B. "Why do you feel like you are going to die?" C. "You are okay now that you are in the hospital." D. "I am sure you are scared, but I am not going to leave you."

D. "I am sure you are scared, but I am not going to leave you." It is important to reassure patients that you are with them and acknowledge their fear. Telling patients that they are not going to die is giving them false reassurance. Asking why they feel they are going to die is not therapeutic. Telling patients that they are okay is also giving false reassurance.

Which temperature would be appropriate for warm cardioplegia? A. 90ºF (32.2ºC) B. 93ºF (33.8ºC) C. 95ºF (35ºC) D. 98ºF (36.6ºC)

D. 98ºF (36.6ºC) The normal body temperature (warm cardioplegia) is 98ºF (36.6ºC). Temperatures below 98ºF (36.6ºC) are identified as cold cardioplegia. As 90ºF, 93ºF, and 95ºF (32.2ºC, 33.8ºC, and 35ºC) are below 98ºF (36.6ºC), they are not considered warm cardioplegia.

Which medication is administered before nitrates to reduce headache discomfort? A. Morphine B. Ibuprofen C. Clopidogrel D. Acetaminophen

D. Acetaminophen Acetaminophen is indicated for relief of headache before the administration of nitrates. Morphine is not indicated for treating headaches. Ibuprofen is not indicated for headaches in patients taking nitrates. Clopidogrel is not indicated for headaches.

Which finding would indicate that a patient who underwent a coronary artery bypass graft (CABG) surgery would need immediate intervention? A. Body temperature: 98.6°F (37°C) B. Potassium level: 4 mEq/L C. Magnesium level: 3 mEq/L D. Blood pressure: 150/90 mm Hg

D. Blood pressure: 150/90 mm Hg Hypertension is a postoperative complication of CABG. A blood pressure reading of 150/90 mm Hg indicates hypertension, which needs immediate intervention. A person's normal body temperature is 98.6°F (37°C); 4 mEq/L indicates normal potassium levels; and 3 mEq/L indicates normal magnesium levels. Because these are all normal values, no immediate intervention is required.

Which is a disadvantage of off-pump coronary artery bypass (OPCAB) surgery performed on patients with coronary artery disease? A. Longer hospital stays B. Increased risk for infection C. Increased cost D. Need for skilled surgeons

D. Need for skilled surgeons The disadvantage of OPCAB surgery is that it requires skilled cardiac surgeons to master the technique. Advantages of OPCAB surgery are shorter hospital stays, decreased risk for infection, and decreased cost.

The patient presents to the emergency department with severe chest pain. After administration of 2 sublingual nitroglycerin tablets, the patient is now reporting pain of 2 on a scale of 1 to 10. Which action by the nurse is a priority? A. Recheck cardiac enzymes. B. Repeat an ECG. C. Continue to monitor the patient. D. Prepare to administer a third nitroglycerin tablet.

D. Prepare to administer a third nitroglycerin tablet. Patients can receive 3 nitroglycerin tablets in 5-minute increments to treat chest pain. The patient indicated pain relief with the first two pills, which would indicate a need to give a third. There is no indication of a need to recheck cardiac enzymes or to repeat an ECG. It is good to continue to monitor the patient, but the priority is administering nitroglycerin.

Which symptom is indicative of a myocardial infarction (MI)? A. Chest pain brought on by exertion or stress B. Substernal chest discomfort occurring at rest C. Substernal chest discomfort relieved by nitroglycerin or rest D. Substernal chest pressure relieved only by opioids

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

Which statement correctly describes the purpose of the intra-aortic balloon pump (IABP) as treatment for cardiogenic shock? A. A laser is used to break up clots that have occluded the coronary artery. B. A balloon is placed in the coronary artery to flatten plaque and improve coronary blood flow. C. An expandable mesh device is inserted into the coronary artery to maintain patency. D. The IABP improves coronary blood flow during diastole and reduces afterload during systole.

D. The IABP improves coronary blood flow during diastole and reduces afterload during systole. The IABP contains a balloon that is synchronized to inflate during diastole and push oxygenated blood into coronary arteries. During systole, the balloon deflates, reducing afterload. The laser procedure that breaks up clots in coronary arteries is known as an atherectomy. Using a balloon to open a coronary artery is done during percutaneous transluminal coronary angioplasty. A supportive mesh device inserted into coronary arteries to maintain patency refers to a stent.

Which assessment finding takes precedence when a patient returns from percutaneous coronary intervention? A. The patient reports thirst. B. Distal pulses are graded as +1/4. C. The patient falls asleep after answering questions. D. The groin dressing has a 10-cm round bloodstain.

D. The groin dressing has a 10-cm round bloodstain. Hemorrhage from the arterial puncture site is of grave concern; the nurse should apply pressure to the site and notify the health care provider immediately. Thirst may be related to NPO status or dehydration from the contrast that was used during the procedure, but it does not take priority over hemorrhage. Sedation may be used during angioplasty or heart catheterization; because the patient is able to be aroused, this is anticipated. Pulses of +1/4 are weak, but equally weak; the nurse should be concerned if the pulse on the affected side was weaker than the other or absent.