CC nclex acute coronary syndrome
CABG COMPLICATIONS
-Bleeding -Fluid & electrolyte imbalances -Hypothermia -Infection
THE MOST COMMON FINDING IN INDIVIDUALS AT RISK FOR SUDDEN CARDIAC DEATH IS
LEFT VENTRICULAR DYSFUNCTION
PQRST ASSESSMENT OF ANGINA
PRECIPITATING EVENTS, QUALITY OF PAIN, RADIATION OF PAIN, SEVERITY OF PAIN, TIMING
THE PERIPHERAL RESISTANCE AGAINST WHICH THE LEFT VENTRICLE PUMPS IS
AFTERLOAD
THE VOLUME OF BLOOD IN THE VENTRICLES AT THE END OF DIASTOLE, BEFORE THE NEXT CONTRACTION IS
PRELOAD
The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for a. relief of chest discomfort. b. a decreased heart rate. c. an increase in BP. d. fewer cardiac dysrhythmias.
A
MEDS USED FOR UNSTABLE ANGINA
ANTIPLATELET THERAPY, BETA BLOCKERS, IV NITROGLYCERIN
THE MYOCARDIUM CONTRACTS DURING
SYSTOLE
2 MAIN FACTORS INFLUENCING BLOOD PRESSURE ARE
CARDIAC OUTPUT AND SYSTEMIC VASCULAR RESISTANCE
A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of a. acute pain related to myocardial ischemia. b. anxiety related to perceived threat of death. c. decreased cardiac output related to cardiogenic shock. d. activity intolerance related to decreased cardiac output.
A
A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST-segment elevation on the ECG d. An increase in cardiac enzyme levels since admission
A
A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI? a. Troponin levels b. C-reactive protein c. High-density lipoprotein (HDL) cholesterol d. Homocysteine
A
When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse? a. Heart rate 100 beats/min b. Chest pain level 8 on a 10-point scale c. Blood pressure (BP) 104/56 mm Hg d. Pedal pulses 2+
A
When planning emergent care for a patient with a suspected MI, the nurse will anticipate administration of A) Oxygen, nitroglycerin, aspirin, and morphine. B) Oxygen, furosemide (Lasix), nitroglycerin, and meperidine. C) Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen. D) Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin).
A
Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? a. Administration of the ordered metoprolol (Lopressor) and aspirin b. Evaluating the patient's response to ambulation in the hallway c. Teaching the patient about the pathophysiology of heart disease d. Completing the documentation for a home health nurse referral
A
-Unstable Angina -Non-ST-segment-elevation myocardial infarction (NSTEMI) -ST-segment-elevation myocardial infarction (STEMI)
ACS
PAIN total occlusion anaerobic metabolism & lactic acid accumulation causes severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration
ACS
When ischemia from angina is prolonged & not immediately reversible,
ACUTE CORONARY SYNDROME (ACS) develops
When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse? a. Heart rate 100 beats/min b. Chest pain level 8 on a 10-point scale c. Blood pressure (BP) 104/56 mm Hg d. Pedal pulses 2+
B
For which of the following antilipemic medications would the nurse question an order in a patient with cirrhosis of the liver?
Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Thus liver disease is a contraindication for atorvastatin.
A 59-year-old man has presented to the emergency department with chest pain. Which of the following components of his subsequent blood work is most clearly indicative of a myocardial infarction (MI)? A) CK-MB B) Troponin C) Myoglobin D) C-reactive protein
B
A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan? a. Have the family members encourage the patient to continue planning for the vacation. b. Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI. c. Implement reality orientation by reminding the patient several times a day about the MI. d. Begin teaching the patient about the normal functions of the heart to improve understanding of the MI.
B
For a patient who has been admitted the previous day to the coronary care unit with an AMI, the nurse will anticipate teaching the patient about a. the pathophysiology of coronary artery disease. b. when patient cardiac rehabilitation will begin. c. home-discharge drugs such as aspirin and -blockers. d. typical emotional responses to MI.
B
Nadolol (Corgard) is prescribed for a patient with angina. In evaluating the effectiveness of the drug, the nurse will monitor for a. improvement in the quality of the peripheral pulses. b. ability to do daily activities without chest discomfort. c. decreased BP and apical pulse rate. d. fewer complaints of having cold hands and feet.
B
Nifedipine (Procardia) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that Procardia will a. help to prevent clotting in the coronary arteries. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. reduce the "fight or flight" response.
B
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. Which of the following allergies is most important for the nurse to assess before this procedure? A) Iron B) Iodine C) Aspirin D) Penicillin
B
The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which of the following ECG changes is most indicative of prolonged or complete coronary occlusion? A) Sinus tachycardia B) Pathologic Q wave C) Fibrillatory P waves D) Prolonged PR interval
B
Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is a. ineffective coping related to depression and anxiety. b. situational low self-esteem related to perceived role changes. c. impaired adjustment related to unwillingness to alter lifestyle. d. ineffective health maintenance related to lack of knowledge.
B
When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient a. that sudden cardiac death events rarely reoccur. b. about the purpose of outpatient Holter monitoring. c. how to self-administer low-molecular-weight heparin. d. to limit activities after discharge to prevent future events.
B
When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, a. "I will need to take an aspirin a day after the surgery to keep the graft open." b. "I will have incisions in my leg where they will remove the vein." c. "They will stop my heart and circulate my blood with a machine during the surgery." d. "They will use an artery near my heart to bypass the area that is obstructed."
B
The nurse would assess a patient with complaints of chest pain for which of the following clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A) Flushing B) Ashen skin C) Diaphoresis D) Nausea and vomiting E) S3 or S4 heart sounds
B,C,D,E
A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? a. captopril (Capoten) b. furosemide (Lasix) c. sildenafil (Viagra) d. diazepam (Valium)
C
A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Heparin will dissolve the clot that is blocking blood flow to the heart. b. Coronary artery plaque size and adherence are decreased with heparin. c. Heparin will prevent the development of clots in the coronary arteries. d. Platelet aggregation is enhanced by IV heparin infusion.
C
A patient with chronic stable angina is being treated with metoprolol (Lopressor). The nurse will suspect that the patient is experiencing a side effect of the metoprolol if a. the patient is restless and agitated. b. the BP is 190/110 mm Hg. c. the cardiac monitor shows a heart rate of 45. d. the patient complains about feeling anxious.
C
A patient with hyperlipidemia has a new order for the bile-acid sequestrant medication colesevelam (Welchol). Which nursing action is appropriate when giving the medication? a. Have the patient take this medication with an aspirin. b. Encourage the patient to take it with a sip of water. c. Give the patient's other medications 2 hours after the Welchol. d. Administer the drug at the patient's bedtime.
C
After the nurse teaches a patient with chronic stable angina about how to use the prescribed nitrates, which statement by the patient indicates that the teaching has been effective? a. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." b. "I will put on the nitroglycerin patch as soon as I develop any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will keep the nitroglycerin in my kitchen window where I can find it quickly."
C
During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.
C
In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin (Nitrostat), the nurse identifies an expected patient outcome of a. stating that nitroglycerin is to be taken only if chest pain develops. b. listing the side effects of nitroglycerin as gastric upset and dry mouth. c. identifying the need to call the emergency medical services (EMS) if chest pain persists 5 minutes after taking nitroglycerin. d. recognizes that taking the nitroglycerin is important to decrease the ongoing atherosclerosis of the coronary arteries.
C
Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which of the following common complications? A) Dehydration B) Paralytic ileus C) Atrial dysrhythmias D) Acute respiratory distress syndrome
C
The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first? a. A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge c. A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old who has a scheduled dose of atenolol (Tenormin) 25 mg PO due
C
Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a a. splitting of the S1 heart sound. b. S3 or S4 gallop rhythm. c. pericardial friction rub. d. holosystolic apical murmur.
C
Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain? a. Sinus tachycardia b. Inverted T wave c. ST-segment elevation d. Frequent PACs
C
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient rates the pain at a level 3 to 5 (0-10 scale). b. The patient states that the pain "wakes me up at night." c. The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet. d. The patient says that the frequency of the pain has increased over the last few weeks.
C
While admitting a patient with an AMI, which action should the nurse carry out first? a. Assess peripheral pulses. b. Check the oxygen saturation. c. Attach the cardiac monitor. d. Obtain the BP.
C
When medical management failed •3 vessel disease or more •Not a candidate for PCI: lesions too long Requires cardiopulmonary bypass •Uses arteries and veins •Longer recovery than PCI •MIDCAB (minimally invasive direct coronary artery bypass)
CABG
SNS response •Release of glycogen •Diaphoresis •Vasoconstriction of peripheral blood vessels •Skin: ashen, clammy, &/or cool to touch -Cardiovascular response •Initially increased HR and BP, then decreased BP due to decreased CO CRACKLES JUGULAR VEIN DISTENTION
CLINICAL MANIFESTATIONS OF MYOCARDIAL INFARCTION
A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to a. determine whether there are any structural defects in the chambers of the heart. b. locate any coronary artery obstructions and administer thrombolytic agents. c. measure the amount of blood being pumped from the heart with each contraction. d. visualize any coronary artery blockages and dilate any obstructed arteries.
D
A patient was admitted to the emergency department 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). Which of the following complications of MI should the nurse anticipate? A) Unstable angina B) Cardiac tamponade C) Sudden cardiac death D) Cardiac dysrhythmias
D
A patient who has chest pain is admitted to the ED, and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. CT scan d. ECG
D
A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Skin flushing after taking the medications b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Generalized muscle aches and pains
D
A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"
D
After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is a. "Sexual intercourse may be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling." b. "You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern." c. "Sexual activity can be resumed whenever you feel like you are ready. Most sexual response is emotional rather than physical." d. "Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."
D
After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Atenolol will increase the strength of my heart muscle." b. "I can expect to feel short of breath when taking atenolol." c. "Atenolol will improve the blood flow to my coronary arteries." d. "It is important not to suddenly stop taking the atenolol."
D
Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? a. BP rises from 118/60 to 126/68 mm Hg. b. Respiratory rate goes from 14 to 22 breaths/min. c. Oxygen saturation drops from 100% to 98%. d. Heart rate increases from 66 to 90 beats/min.
D
For which of the following is percutaneous coronary intervention (PCI) most clearly indicated? A) Chronic stable angina B) Left-sided heart failure C) Coronary artery disease D) Acute myocardial infarction
D
The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain worsens when the patient raises the arms. b. The pain increases with deep breathing. c. The pain is relieved after the patient takes nitroglycerin. d. The pain has persisted longer than 30 minutes.
D
The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider? a. The oral temperature is 100.8° F (38.2° C). b. The white blood cell count (WBC) is 12,000/l. c. The patient denies ever having a heart attack. d. The lungs have crackles audible to the midline.
D
THE MYOCARDIUM RELAXES DURING
DIASTOLE
EMERGENCY MANAGEMENT OF MI
Establish IV line -NTG sublingual -Aspirin chewable -Morphine sulfate IV for pain -Oxygen by nasal cannula 2-4L/min -EKG monitoring & vital signs
Result of sustained ischemia (>20 minutes), causing irreversible myocardial cell death (necrosis) •Necrosis of entire thickness of myocardium takes 4-6 hours -Transmural (full-thickness) MI •The degree of altered function depends on the area of the heart involved & the size of the infarct •Contractile function of the heart is disrupted in areas of myocardial necrosis •Most MI's involve the left ventricle
MYOCARDIAL INFARCTION
DISCHARGE TEACHING S/P CABG
Medication -Physical Activity •Isometric exercises- HR & BP increase rapidly therefore should be limited •Isotonic exercises- provide a safe steady load on the heart -Sexual activity •NTG before
A PT 2 DAYS POST MI C/O CHEST PAIN, STATES IT HURTS WHEN I TAKE A DEEP BREATH, WHAT IS PRIORITY
OBTAIN VITAL SIGNS ANS AUCULTATE FOR A PERICARDIAL FRICTION RUB
CHEST PAIN R/T ISCHEMIA
RELIEVED BY REST, NITROGLYCERINE OR BOTH
ELECTRICAL IMPULSE OF THE HEART IS GENERATED BY THE
SA NODE
TROPONIN
SECRETED BY THE CELLS AFTER CARDIAC DAMAGE, RISES FASTER THAN CKMB. RELEASED FROM DEAD CARDIAC CELLS.
CKMB
TOTAL CK CREATININE KINASE, SHOWS DAMAGE TO CARDIAC MUSCLE. RELEASED FROM DEAD CARDIAC CELLS.
