Chapter 20: Care of Patients with Coronary Artery Disease and Cardiac Surgery

The drug alteplase (t-PA) is given to the patient with a myocardial infarction (MI). Which statement accurately describes the purpose of this medication? a. "Alteplase (t-PA) dissolves the obstruction in the coronary artery." b. "Alteplase (t-PA) dilates vessels to relieve pain." c. "Alteplase (t-PA) strengthens cardiac contraction." d. "Alteplase (t-PA) increases cardiac output."

ANS: A Alteplase (t-PA) is a thrombolytic drug that will dissolve the clot if given within 12 hours of the MI.

The nurse uses a diagram to show how obstruction of an artery has caused an area of necrosis called a(n) _________.

ANS: infarct infarction Tissue necrosis from arterial obstruction is referred to as an infarct.

The nurse is aware that the patient's cardiac rehabilitation levels of physical activity are designated through ____________ units.

ANS: metabolic equivalent MET One MET is the amount of oxygen needed by the body at rest. The patient's rehabilitation program slowly progresses stepwise to higher energy expenditures over a period of months.

The nurse is caring for a post-myocardial infarction (MI) patient. The patient questions the reason for a stool softener and denies constipation. Which statement indicates that the patient accurately understands the nurse's teaching? a. "Stool softeners help me keep from straining during bowel movements, which can lower my heart rate." b. "Stool softeners help me to get rid of extra wastes that can harm my heart." c. "Stool softeners help reduce swelling that can increase work on my heart." d. "Stool softeners help to reduce discomfort from gas pains.

ANS: A Bearing down or straining at stool can stimulate the vagal nerve and induce bradycardia.

The patient with angina asks the nurse how a daily dose of 81 mg of aspirin is helpful. Which reply is best? a. Low-dose aspirin helps reduce clotting. b. Low-dose aspirin helps dilate coronary vessels. c. Low-dose aspirin helps alleviates pain associated with angina. d. Low-dose aspirin helps lower cholesterol.

ANS: A Daily doses of aspirin reduce clotting by prolonging clotting time, thus helping prevent clots that can cause an MI.

A patient who presented to the emergency room with a myocardial infarction (MI) becomes pale, diaphoretic, and hypotensive. What action should the nurse take first? a. Notify the physician immediately. b. Ensure that the patient has patent IV access. c. Request assistance from respiratory therapy. d. Inform the patient's family of the change in status.

ANS: A If the left ventricle is badly damaged, cardiogenic shock may occur. Signs and symptoms are those that accompany decreased cardiac output, such as decreased BP, confusion, restlessness, diaphoresis, rapid and thready pulse, increased respiratory rate, cold and clammy skin, and diminishing urinary output to less than 20 mL/hr. This condition is a medical emergency that requires immediate notification of the physician. The nurse should then ensure that the IV is patent. Respiratory therapy assistance will likely be beneficial, especially if the patient's condition further deteriorates. The nurse should finally notify the patient's family about the change in status.

The nurse performs patient teaching about minimally invasive direct coronary artery bypass (MIDCAB). Which statement indicates that the patient needs further instruction? a. "It frightens me to think that my heart will be stopped for a long time during surgery." b. "This surgery bypasses my artery that is blocked, and replaces it with sections of a vein or artery taken from another part of my body." c. "This surgery will hopefully control my angina since nothing else we have tried has worked." d. "I may come out of surgery with vessels removed from my legs."

ANS: A The MIDCAB procedure is less invasive than the traditional coronary artery bypass graft (CABG) procedure and does not require the patient be placed on the heart-lung machine due to stopping the heart for an extended period. Both procedures are used to treat angina that has not responded to more conservative treatment and utilize either the mammary artery or sections of the saphenous vein for the graft.

The nurse is caring for a patient admitted with chest pain to rule out a myocardial infarction (MI). The nurse observes that the patient is experiencing electrocardiogram (ECG) changes and reviews new laboratory results. Which laboratory value should the nurse report immediately? a. Troponin of 2.4 mcg/L b. Potassium of 3.4 mEq/L c. Creatine phosphokinase of 134 IU/L d. Sodium of 133 mEq/L

ANS: A The patient has a significantly elevated troponin. The abnormal troponin, along with ECG changes, indicates that the patient is likely experiencing an MI. (Elevated troponin levels are most indicative of an MI as these enzymes are specific to heart muscle damage.) While the nurse should report the abnormally low potassium of 3.4 (low normal) sodium, these findings are of lesser priority than the elevated troponin.

The nurse is caring for a patient who underwent a transfemoral cardiac catheterization with coronary angiography earlier in the day. The patient denies pain and no longer requires bed rest. The groin is soft with no palpable hematoma. Which postprocedure care is most important for the patient at this time? a. Encourage increased fluid intake. b. Administer pain medications as ordered. c. Obtain vital signs every 15 minutes. d. Assist the patient with ambulation.

ANS: A The procedure uses a large volume of dye, which can be harmful to the kidneys. Increasing fluid intake is the priority focus for care at this time after hemostasis is obtained. Keeping the patient hydrated increases the rate of urine flow, dilutes the urine, and helps prevent kidney damage as the contrast is excreted. The patient denies pain. Vital signs are taken every 15 minutes for the first hour and are checked progressively less frequently unless there is evidence of bleeding or instability. The patient can now ambulate, but ambulation is a lesser priority than flushing out the hypertonic dye.

The nurse is caring for a patient with uncontrolled hypertension, diabetes, asthma, and gastroesophageal reflux disease (GERD). Which problem serves as a contraindication for a thrombolytic agent? a. Uncontrolled hypertension b. Diabetes c. Asthma d. GERD

ANS: A Thrombolytic agents are contraindicated in people with uncontrolled hypertension, GI bleeds, recent intracranial or intraspinal surgery, or aneurysm because of threat of excessive bleeding.

The nurse encourages the patient who has had a myocardial infarction (MI) to enroll in the outpatient cardiac rehabilitation in order to receive which service(s)? (Select all that apply.) a. Nutritional counseling b. Supervised progressive exercise c. stress reduction techniques d. Sexual counseling e. Administration of cardiotonic drugs

ANS: A, B, C Cardiac rehab services include nutritional counseling, specialized exercise programs, and stress-reduction techniques. Sexual counseling and administration of medications are not services of cardiac rehab.

The nurse instructs a patient that the pain of angina is due to ischemia of the myocardium. Which factors are causative agents for angina? (Select all that apply.) a. Exertion b. Emotional excitement c. Eating heavy meals d. Exposure to cold e. Allergic reactions

ANS: A, B, C, D Angina may be caused by exertion, emotional excitement, eating heavy meals, and exposure to cold. Angina is not brought on by allergy.

The nurse clarifies that the MONA protocol for drug administration in the emergent stage of a myocardial infarction (MI) involves the use of which therapies? (Select all that apply.) a. Aspirin b. Morphine c. Nitrates d. Antibiotics e. Oxygen f. Anticoagulants

ANS: A, B, C, E Morphine, oxygen, nitrates, and aspirin are the components of MONA therapy. Antibiotics are not part of the MONA protocol.

The nurse is aware that a positive diagnosis of a myocardial infarction (MI) is based on which diagnostic test finding(s)? (Select all that apply.) a. Electrocardiographic (ECG) changes in the QRS complex b. Elevation of low-density lipoprotein (LDL) c. Elevation of troponin levels d. Elevated white blood cell (WBC) count e. Elevated bilirubin levels

ANS: A, C Diagnosis of MI is made by patient history, ECG, and serum cardiac enzyme levels. Elevated LDL, WBC, or bilirubin levels are not indicative of an MI.

Which herbs and supplements lower cholesterol? (Select all that apply.) a. Garlic b. Bananas c. Oatmeal d. St. John's wort e. Soy products

ANS: A, C, E Garlic, whole-grain foods, and soy products are thought to decrease cholesterol. Bananas and St. John's wort are not known to lower cholesterol.

The nurse is caring for a patient with agina pectoris who asks what happens to make his body experience pain. The nurse explains that pain results from which underlying causative factor? a. Congestion that backs up into the lungs b. Inadequate blood flow and poor oxygen supply c. Edema from fluid overload d. Inflammation in the vessels

ANS: B Angina pectoris (chest pain) occurs when blood supply to the heart is decreased or totally obstructed. Pain results from ischemia (inadequate blood and oxygen supply).

The nurse is educating a patient on a low-fat, low-cholesterol diet after a myocardial infarction (MI). Which food choice should the nurse recommend? a. "Avoid eating frozen foods." b. "Replace a serving of red meat with a serving of fish." c. "Use nondairy creamer in your decaffeinated coffee." d. "Drink a serving of grapefruit juice each day."

ANS: B Fish have a high content of omega-3 fatty acids, which are helpful in reducing cholesterol. Not all frozen foods are unhealthy. Frozen vegetables with no sodium added are a good choice for a low-fat, low-cholesterol diet. Nondairy creamer is high in trans fat and saturated fat. Grapefruit juice often interferes with metabolism of a variety of medications.

The patient being evaluated for a heart transplant asks the nurse what the survival rate is. Which response is best for the nurse to make? a. "I'm not really sure. It is better if you ask your surgeon." b. "Every patient has different circumstances, but the average 5-year survival rate is 79%." c. "The survival rate is excellent. Almost all patients with a heart transplant live past 10 years." d. "There are not any really good statistics for me to give you an accurate estimate."

ANS: B Identifying that individual cases vary while giving accurate statistics is the most helpful response. Stating "I'm not really sure" does not instill confidence in the nurse's ability or knowledge. Although a significant number of patients live past 10 years following heart transplant, responding that almost all patients live past 10 years is inaccurate and instills false hope.

How does a myocardial infarction (MI) alter the pumping efficiency of the heart? a. An MI reduces the impulse from the sinoatrial node. b. An MI causes myocardial necrosis. c. An MI shunts all myocardial blood flow to a specific cardiac region. d. An MI causes myocardial swelling and inflammation.

ANS: B Myocardial necrosis (damaged or dead heart muscle tissue) cannot contract effectively, which decreases pumping efficiency (cardiac output).

The nurse is caring for a 38-year-old African American patient with diabetes. The patient manages her diabetes with dietary control, takes oral contraceptives, and is a nonsmoker. Which characteristic(s) in this patient's history increase the patient's risk for coronary artery disease (CAD)? (Select all that apply.) a. Age b. Race c. Diabetes d. Nonsmoker status e. Use of oral contraceptives

ANS: B, C, E African Americans have an ethnic tendency to CAD. Taking birth control pills and diabetes are both risk factors for CAD. Older patients are at increased risk for CAD, and a nonsmoking status decreases the likelihood of developing CAD.

The nurse assesses a friction rub in a patient who is 2 days post-myocardial infarction (MI). The nurse recognizes this finding indicates which problem? a. A recurrent MI b. Pleural effusion c. Pericarditis d. Angina

ANS: C Friction rubs occur in pericarditis when the inflamed area of the infarct rubs the pericardium.

The patient states that he had a cardiac catheterization 10 years ago and wonders if any of the postprocedure care has changed. Which response by the nurse is most accurate? a. "We will only roll you to the same side as the catheter insertion site." b. "You will lay flat for several hours, and we will place a sandbag over the dressing in the groin." c. "You will most likely be able to ambulate within a few hours if your doctor uses an arterial closure device at the catheter insertion site." d. "We will encourage you to flex and extend your legs when you return from the procedure to prevent a clot from forming at the insertion site."

ANS: C Most physicians use an arterial closure device at the puncture site, which enables the patient to be ambulatory within 2 hours after the cardiac catheterization procedure. The patient may be turned to either side. Sandbags were used in the past to prevent bleeding from the puncture site and the patient had to lay flat for several hours. Flexing and extending the legs immediately after the procedure would likely cause bleeding from the site.

The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates that the nurse's teaching has been successful? a. "I will need to have blood work every month while taking Zocor." b. "I should take my Zocor with grapefruit juice to help absorption. c. "I should call my doctor if I experience unexplained muscle pain." d. "I should take Zocor an hour before my biggest meal of the day."

ANS: C Statins can injure muscle tissue and are toxic to the liver in some patients. Patients should report any unexplained muscle tenderness or pain persisting for more than a few days. Laboratory tests for liver enzymes are recommended at the start of therapy and only when clinically indicated. Grapefruit juice interferes with drug metabolism and should be avoided to prevent increased risk of toxicity. Zocor can be taken without regard to meals.

The nurse is caring for a male patient with angina who has a new prescription for sublingual nitroglycerin. What information is most important for the nurse to include in the teaching plan? a. Nitroglycerin tablets expire 3 months after the bottle is opened. b. Take a second tablet 15 minutes after the first dose and call the physician if pain persists. c. Store nitroglycerin tablets in a cool, dark location. d. Nitroglycerin may cause an unsafe drop in heart rate when combined with certain medications for erectile dysfunction

ANS: C Sublingual nitroglycerin tablets should be kept in a cool, dark place and should be carried by the patient at all times. If chest pain persists after the first dose, the patient should repeat the dose in 5 minutes. The patient should contact emergency services, not the physician. Nitroglycerin may cause an unsafe drop in blood pressure (BP) if combined with certain medications for erectile dysfunction.

During the acute phase following a myocardial infarction (MI), the nurse anticipates that the patient may require a temporary pacemaker in which situation(s)? (Select all that apply.) a. The patient's heart rate remains above 120 beats/min. b. The patient experiences worsening anginal pain. c. The patient experiences complete heart block. d. The patient's systolic BP drops to 60. e. The patient's pulse rate remains below 40 beats/min.

ANS: C, E A temporary pacemaker is warranted when the patient's pulse consistently remains below 40 beats/min and when the patient experiences complete heart block. Complete heart block means that the electrical impulse for contraction does not go through the atrioventricular node to the ventricles and the ventricles are not signaled to contract. Tachycardia, above 100, continued angina pain, and hypotension are not correct indications for a pacemaker.

The 60-year-old female in the post-coronary care unit confides to the nurse, "My life is over. I'll never be able to care for my family, take a vacation, or work in my garden." Which response is most supportive? a. "You are doing great! You can do all of those things in a few weeks." b. "You may have to give up some things, but there are other activities you might enjoy." c. "You are feeling a little blue today. Would you like medication to help your anxiety?" d. "You sound a little down. Tell me what you think is going to keep you from those activities; we might be able to address the problems."

ANS: D Helping patients identify and face depression is helpful in dispelling it, and talking about her concerns will open up conversation and address the concerns in a problem-solving approach. Telling her that she will be able to resume all activities may be instilling false hope. Medication is not warranted at this point.

The nurse is explaining the difference between exertional angina and unstable angina. Which statement about unstable angina is accurate? a. Unstable angina occurs with moderate exercise. b. Unstable angina occurs when the blood pressure increases sharply. c. Unstable angina occurs when the body reacts to high stress levels. d. Unstable angina occurs unpredictably, even in sleep.

ANS: D Unstable angina attacks are unpredictable and do not follow a pattern, as do stable angina attacks. Unstable angina can progress into a myocardial infarction (MI) and a medical emergency.

The nurse is caring for a female patient with a family history of heart disease who is undergoing a workup for cardiovascular disease. Which finding is most concerning to the nurse? a. Fainting b. Dry mouth c. Dizziness d. Fatigue

ANS: D Women frequently experience fatigue with heart disease. Many women do not even experience chest pain. Fainting, dry mouth, and dizziness are not typical signs of heart disease in women.