CH 27: CAD and MI

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? a. Assess the client's level of pain and administer prescribed analgesics. b. Assess the client's level of anxiety and provide emotional support. c. Prepare the client for pulmonary artery catheterization. d. Ensure that the client's family is kept informed of the client's status.

a. Assess the client's level of pain and administer prescribed analgesics. Rationale: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and family members should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

Which is a diagnostic marker for inflammation of vascular endothelium? a. C-reactive protein (CRP) b. Low-density lipoprotein (LDL) c. High-density lipoprotein (HDL) d. Triglyceride

a. C-reactive protein (CRP) Rationale: CRP is a marker for inflammation of the vascular endothelium. LDL, HDL, and triglycerides are not markers of vascular endothelial inflammation. They are elements of fat metabolism.

Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? a. Cardiac tamponade b. Fluid overload c. Hypertension d. Hypothermia

a. Cardiac tamponade Rationale: Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent? a. Clopidogrel b. Isosorbide mononitrate c. Metoprolol d. Diltiazem

a. Clopidogrel Rationale: 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.

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient? a. Decreases the sinoatrial node automaticity b. Increases the atrioventricular node conduction c. Increases the heart rate d. Creates a positive inotropic effect

a. Decreases the sinoatrial node automaticity Rationale: Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

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? a. Nitroglycerin SL b. Chest x-ray c. Serum electrolytes d. Ativan 1 mg orally

a. Nitroglycerin SL Rationale: 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? a. Protamine sulfate b. Alteplase c. Clopidogrel d. Aspirin

a. Protamine sulfate Rationale: 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? a. Prothrombin time (PT) or international normalized ratio (INR) b. Hourly IV infusion c. Vascular sites for bleeding d. Urine output

a. Prothrombin time (PT) or international normalized ratio (INR) Rationale: 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.

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? a. fatty deposits in the lumen of arteries b. cholesterol plugs in the lumen of veins c. blood clots in the arteries d. emboli in the veins

a. fatty deposits in the lumen of arteries Rationale: 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 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. a. Absent P-waves b. Abnormal Q-waves c. T-wave hyperactivity and inversions d. ST-segment elevations d. U-wave elevations

b. Abnormal Q-waves c. T-wave hyperactivity and inversions d. ST-segment elevations Rationale: 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.

The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration? a. Measure the blood pressure for hypertension. b. Count the respiratory rate for bradypnea. c. Check the radial pulse for dysrhythmias. d. Measure urinary output for dehydration.

b. Count the respiratory rate for bradypnea. Rationale: The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.

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? a. To dilate coronary arteries b. To decrease workload of the heart c. To decrease homocysteine levels d. To prevent angiotensin II conversion

b. To decrease workload of the heart Rationale: Beta-adrenergic blockers are used in the treatment of CAD to decrease the 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 client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks? a. Myoglobin b. Troponin c. Total creatine kinase d. CK-MB

b. Troponin Rationale: Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin peaks within 12 hours after the onset of symptoms. Total creatine kinase (CK) returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause? a. Chest pain is typical b. Vague symptoms c. Decreased sensation to pain d. Gender bias

b. Vague symptoms Rationale: 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.

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? a. decrease anxiety b. enhance myocardial oxygenation c. administer sublingual nitroglycerin d. educate the client about his symptoms

b. enhance myocardial oxygenation Rationale: 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 caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? a. Assess the client's mental and emotional status. b. Assess the skin of the client. c. Assess the characteristics of chest pain. d. Assess for any kind of drug abuse.

c. Assess the characteristics of chest pain. Rationale: 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 client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? a. Pulse rate of 84 beats/minute b. Respiration 26 breaths/minute c. Blood pressure 84/52 mm Hg d. Temperature of 100.2° F (37.9° C)

c. Blood pressure 84/52 mm Hg Rationale: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? a. Prolonged PR interval b. Absent Q wave c. Elevated ST segment d. Widened QRS complex

c. Elevated ST segment Rationale: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin? a. Nausea, vomiting, depression, fatigue, and impotence. b. Sedation, nausea, vomiting, constipation, and respiratory depression. c. Headache, hypotension, dizziness, and flushing. d. Flushing, dizziness, headache, and pedal edema.

c. Headache, hypotension, dizziness, and flushing. Ratinale: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic that relieves pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? a. Calcium b. Magnesium c. Potassium d. Sodium

c. Potassium Rationale: Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

A nurse is assigned to care for a recently admitted client who has been diagnosed with refractory angina. What symptom will the nurse expect the client to exhibit? a. Predictable and consistent pain that occurs on exertion and is relieved by rest b. Pain that may occur at rest, but the threshold for pain is lower than expected c. Severe, incapacitating chest pain d. Pain that occurs more frequently and lasts longer than the pain usually seen with stable angina

c. Severe, incapacitating chest pain

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? a. cerebral bleeding b. I.M. injection c. myocardial necrosis d. skeletal muscle damage due to a recent fall

c. myocardial necrosis Rationale: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse? a. weight gain of 6 ounces b. serum glucose of 124 mg/dL c. potassium level of 6 mEq/L d. bilateral rales and rhonchi

c. potassium level of 6 mEq/L Rationale: Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L. An elevated blood sugar is common postoperatively, and the weight gain is not significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed.

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? a. "Client performs relaxation exercises three times per day to reduce stress." b. "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." c. "Client verbalizes an understanding of the need to seek emergency help if heart rate increases markedly while at rest." d. "Client walks 4 miles in 1 hour every day."

d. "Client walks 4 miles in 1 hour every day." Rationale: 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

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? a. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. b. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. c. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Rationale: Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding? a. "What color is your urine?" b. "Is your skin drier than normal?" c. "Do you have any breathing problems?" d. "How is your appetite?"

a. "What color is your urine?" Rationale: 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 reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease? a. Assess chest pain and administer prescribed drugs and oxygen b. Assess blood pressure and administer aspirin c. It is not important to assess the client or to notify the physician d. Assess the client's physical history

a. Assess chest pain and administer prescribed drugs and oxygen Rationale: The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse? a. Cholesterol is within the recommended guidelines and the client doesn't need to lower it. b. Client should take statin medication and not worry about cholesterol. c. Client should begin a running program, working up to 2 miles per day. d. The nurse will ask the dietitian to talk with the client about modifying the diet.

d. The nurse will ask the dietitian to talk with the client about modifying the diet. Rationale: A dietitian can help the client decrease the fat in the diet and make other beneficial dietary modifications. This client's total cholesterol isn't within the recommended guidelines; it should be less than 200 mg/dl. LDL should be less than 79 mg/dl, and HDL should be greater than 40 mg/dl. Although this client should take statin medication, the client should still be concerned about cholesterol levels and make other lifestyle changes, such as dietary changes, to help lower it. The client should increase activity level, but doesn't need to run 2 miles per day.

The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain? a. incomplete blockage of a major coronary artery b. a destroyed part of the heart muscle c. complete closure of an artery d. a lack of oxygen in the heart muscle cells

d. a lack of oxygen in the heart muscle cells Rationale: 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.