Chapter 27
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient? A) He will remain on bed rest for 48 to 72 hours after the procedure. B) He will be given vitamin K infusions to prevent bleeding following PCI. C) A sheath will be placed over the insertion site after the procedure is finished. D) The procedure will likely be repeated in 6 to 8 weeks to ensure success.
Ans: A sheath will be placed over the insertion site after the procedure is finished. Feedback: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are administered during PCI.
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified? A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity
Ans: Obesity, inactivity, diet, and smoking Feedback: The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.
The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A) P wave inversion B) T wave inversion C) Q wave changes with no change in ST or T wave D) P wave enlargement
Ans: T wave inversion Feedback: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
Family members bring a patient 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? A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.
Ans: The symptoms indicate an acute coronary episode and should be treated as such. Feedback: Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patient's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse's most appropriate action? A) Call for assistance and initiate cardiopulmonary resuscitation. B) Reposition the patient's leg in a nondependent position. C) Promptly remove the femoral sheath. D) Call for help and apply pressure to the access site.
Ans: Call for help and apply pressure to the access site. Feedback: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen
Ans: Morphine Feedback: The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A) Abrupt closure of the coronary artery B) Venous insufficiency C) Bleeding at the insertion site D) Retroperitoneal bleeding E) Arterial occlusion
Ans: Abrupt closure of the coronary artery, Bleeding at the insertion site, Retroperitoneal bleeding, Arterial occlusion Feedback: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.
The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patient's care plan? A) Facilitate daily arterial blood gas (ABG) sampling. B) Administer supplementary oxygen, as needed. C) Have patient maintain supine positioning when in bed. D) Perform chest physiotherapy, as indicated.
Ans: Administer supplementary oxygen, as needed. Feedback: Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.
A 48-year-old man presents to the ED complaining of 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 CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.
Ans: Begin ECG monitoring. Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient? A) Hyperlipidemia B) Bleeding at insertion site C) Left ventricular hypertrophy D) Congestive heart failure
Ans: Bleeding at insertion site Feedback: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.
The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A) Coronary artery bypass graft (CABG) B) Percutaneous transluminal coronary angioplasty (PTCA) C) Atherectomy D) Cardiopulmonary bypass
Ans: Cardiopulmonary bypass Feedback: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.
A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patient's daily medication administration record, the nurse should anticipate administering what drug? A) Ibuprofen B) Clopidogrel C) Dipyridamole D) Acetaminophen
Ans: Clopidogrel Feedback: Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A) Document the patient's low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the patient's physician and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the patient's IV fluid to prompt an increase in renal function.
Ans: Contact the patient's physician and suggest assessment of fluid balance and renal function. Feedback: Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis
Ans: Dyspnea, Unusual fatigue, Syncope Feedback: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.
When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? A) Exercise increases the heart's oxygen demands. B) Exercise causes vasoconstriction of the coronary arteries. C) Exercise shunts blood flow from the heart to the mesenteric area. D) Exercise increases the metabolism of cardiac medications.
Ans: Exercise increases the heart's oxygen demands. Feedback: Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? A) Brachial artery B) Brachial vein C) Femoral artery D) Greater saphenous vein
Ans: Greater saphenous vein Feedback: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A) Increase in the size of the artery's lumen B) Decrease in arterial blood flow in relation to venous flow C) Increase in the patient's resting heart rate D) Increase in the patient's level of consciousness (LOC)
Ans: Increase in the size of the artery's lumen Feedback: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patient's LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective breathing pattern related to decreased cardiac output B) Anxiety related to fear of death C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D) Impaired skin integrity related to CAD
Ans: Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Feedback: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.
.The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse's most recent assessment reveals that the patient's left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurse's best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patient's physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.
Ans: Inform the patient's physician of this assessment finding. Feedback: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.
Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject? A) Symptoms of hypovolemia B) Symptoms of low blood pressure C) Complications requiring graft removal D) Intubation and mechanical ventilation
Ans: Intubation and mechanical ventilation Feedback: Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important that patients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most patients. Teaching would also generally not include rare complications that would require graft removal.
The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient's symptoms are due to an MI, what will have happened to the myocardium? A) It may have developed an increased area of infarction during the time without treatment. B) It will probably not have more damage than if he came in immediately. C) It may be responsive to restoration of the area of dead cells with proper treatment. D) It has been irreparably damaged, so immediate treatment is no longer necessary.
Ans: It may have developed an increased area of infarction during the time without treatment. Feedback: When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B) Morphine sulphate, oxygen, and bed rest C) Oxygen and beta-adrenergic blockers D) Bed rest, albuterol nebulizer treatments, and oxygen
Ans: Morphine sulphate, oxygen, and bed rest Feedback: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness
Ans: Numbness, Weakness Feedback: Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.
A patient presents to the ED in distress and complaining of "crushing" chest pain. What is the nurse's priority for assessment? A) Prompt initiation of an ECG B) Auscultation of the patient's point of maximal impulse (PMI) C) Rapid assessment of the patient's peripheral pulses D) Palpation of the patient's cardiac apex
Ans: Prompt initiation of an ECG Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.
A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following? A) Reducing the heart's workload by decreasing heart rate and myocardial contraction B) Preventing platelet aggregation and subsequent thrombosis C) Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D) Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain
Ans: Reducing the heart's workload by decreasing heart rate and myocardial contraction Feedback: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia
Ans: Throbbing headache or dizziness Feedback: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care? A) With the patient, clarify the surgical procedure that will be performed. B) Withhold the patient's scheduled medications for at least 12 hours preoperatively. C) Inform the patient that health teaching will begin as soon as possible after surgery. D) Avoid discussing the patient's fears as not to exacerbate them.
Ans: With the patient, clarify the surgical procedure that will be performed. Feedback: Preoperatively, it is necessary to evaluate the patient's understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the patient's medication regimen if necessary; this will vary from patient to patient. Fears should be addressed directly and empathically.
