Chapter 25: Caring for Clients with Disorders of Coronary and Peripheral Blood Vessels
The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be?
2.0-3.0
A 75-year-old is to have a carotid artery stent placed in the morning. Which of the following is an appropriate nursing action when caring for older patients scheduled to undergo cardiac surgery?
Administer narcotics with caution.
A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:
Alteplase
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?
Assess the client's level of pain and administer prescribed analgesics.
The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments?
Balancing myocardial oxygen supply with demand
A client presents to the ED reporting severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CC
Begin ECG monitoring.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?
"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up."
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education?
"I'll make sure that I don't cross my legs when I'm resting in bed."
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?
"The pain occurred while I was mowing the lawn."
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
The nurse has been asked to explain the cause of angina pain to a patient's family. Choose the best statement. The pain is due to:
A lack of oxygen in the heart muscle that causes the death of cells.
Which s the analgesic of choice for acute myocardial infarction (MI)?
Aspirin
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?
Assess chest pain and administer prescribed drugs and oxygen
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse?
Central venous pressure reading of 1
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication
A patient is given a prescription for Lopressor, a beta-blocker, after being examined by his health care provider. Select the most important information the nurse should provide.
Don't suddenly stop taking the medication without calling your health care provider.
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?
Dorsiflex the foot while the leg is elevated to check for calf pain.
When discussing angina pectoris secondary to atherosclerotic disease with a client, the client asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?
Exercise increases the heart's oxygen demands.
When being assessed by her new nurse practitioner, a woman states that she has had Raynaud's disease for many years, a problem that occasionally affects her quality of life. When performing health education surrounding this problem, what should the nurse emphasize?
Helping the woman identify and avoid the specific triggers of her problem
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:
Hemorrhage.
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?
Hyperbaric oxygen
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain
The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
The nurse is caring for an adult patient who had symptoms of unstable angina during admission to the hospital. The most appropriate nursing diagnosis for the discomfort associated with angina is what?
Ineffective cardiopulmonary tissue perfusion secondary to coronary artery disease (CAD)
The nurse is taking a health history on a new patient. The patient reports experiencing pain in the left lower leg and foot when walking, but claims that the pain is relieved with rest. The nurse notes that the patient's left lower leg is slightly edematous and hairless. What should the nurse suspect that the patient may be experiencing?
Intermittent claudication
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?
International normalized ratio (INR) is 2.5.
The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?
It may have developed an increased area of infarction during the time without treatment.
The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client?
Morphine
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?
Numbness, cool skin temperature, and pallor
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of what health problem?
Peripheral artery disease (PAD)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours?
Peripheral pulses every 15 minutes after surgery
The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?
Protamine sulfate
The physician has prescribed a thrombolytic for a patient who has chest pain unrelieved by nitroglycerin. Which of the following should the nurse assess before administering thrombolytic agents to older patients?
Streptococcal infections
A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)?
The patient has at least a 70% occlusion of a major coronary artery.
Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
The symptoms indicate an acute coronary episode and should be treated as such.
A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?
Throbbing headache or dizziness
A patient with angina is beginning nitroglycerin. Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what?
Throbbing headache or dizziness
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?
Venous insufficiency
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?
Ulceration
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?
Unstable
A client presents to the clinic reporting the inability to grasp objects with her right hand. The client's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary provider may diagnose the woman with what health problem?
Upper extremity arterial occlusive disease
A community health nurse is providing an educational event at the local seniors' center. The topic the nurse is speaking about is varicose veins. What would the nurse suggest as proactive preventative measure for varicose veins?
Walking for several minutes every hour to promote circulation
A 60-year-old woman has been brought to the emergency department (ED) by ambulance after she experienced a sudden onset of dyspnea and phoned 911. The woman is obese but claims an unremarkable medical history and denies chest pain. When assessing this patient, the nurse in the ED should be aware that:
Women often present with an MI much differently than do men.
A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of:
aspirin or clopidogrel (Plavix).
A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug?
calcium-channel blocker
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine
causes vasospasm.
A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.
• Hyperlipidemia • Tobacco use • Obesity
