Chapter 27: Management of Patients with Coronary Vascular Disorders - ML4

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?

"Removing the patch at night prevents drug tolerance while keeping the benefits." Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night.

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." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding?

"What color is your urine?" 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

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication?

160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many milliliters per hour will the nurse infuse this solution? Record your answer using a whole number.

24 (1200 units/25,000 units) X 500 mL = 24 mL.

A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse?

3 minutes Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally alleviates the pain of ischemia within 3 minutes.

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?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. 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.

After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse's initial action?

Apply manual pressure at the site of the insertion of the sheath.

An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take?

Assess for factors that may be causing the client's delirium. Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.

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 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.

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication?

Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia.

The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult.

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol?

Atropine Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.

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?

Blood pressure 84/52 mm Hg 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

Which is a diagnostic marker for inflammation of vascular endothelium?

C-reactive protein (CRP) 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.

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 The central venous pressure (CVP) reading of 1 is low (2-6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery.

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is mostindicative of a possible myocardial infarction (MI)?

Chest discomfort not relieved by rest or nitroglycerin

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent?

Clopidogrel Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect?

Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available.

A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display?

Fatty deposits in the lumen of arteries Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.

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?

Headache, hypotension, dizziness, and flushing. 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.

Which of the following is inconsistent as a condition related to metabolic syndrome?

Hypotension A diagnosis of metabolic syndrome includes three of the following conditions: insulin resistance, abdominal obesity, dyslipidemia, hypertension, proinflammatory state, and prothrombotic state.

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?

Hypotension The patient is observed for any adverse effects of opioids, which may include respiratory depression, hypotension, ileus, or urinary retention. If serious side effects occur, an opioid antagonist, such as Narcan, may be used.

The nurse notes that the post cardiac surgery client demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025). What will the nurse anticipate the health care provider will order?

Increase intravenous fluids Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume.

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply.

Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Renew the supply every 6 months. Take the tablet in anticipation of any activity that can produce pain. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

Monitor the site for bleeding or hematoma. The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma

Which s the analgesic of choice for acute myocardial infarction (MI)?

Morphine The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety. Aspirin is an antiplatelet medication.

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

Morphine sulfate (Morphine) Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen.

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?

Potassium 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.

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 Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin).

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?

Relieved by rest and nitroglycerin One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?

ST elevation

The client is prescribed nadolol for hypertension. What is the reason the nurse will teach the client not to stop taking the medication abruptly?

The abrupt stop can cause a myocardial infarction. Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop.

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. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

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?

To decrease workload of the heart 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

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks?

Troponin Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage.

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

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?

Vague symptoms 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.

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?

Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure.

The nurse is explaining the cause of angina pain to a client. What will the nurse say caused the pain?

a lack of oxygen in the heart muscle that causes the death of cells Impeded blood flow, due to blockage in a coronary artery, deprives the cardiac muscle cells of oxygen, thus leading to a condition known as ischemia. Artery blockage or closure leads to myocardial death. The destroyed part of the heart is a myocardial infarction.

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 be prescribed long-term administration of which drug?

aspirin or clopidogrel. After PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Health care providers order heparin for anticoagulation during this procedure; some health care providers discharge clients with a prescription for long-term warfarin or low-molecular-weight heparin therapy.

The nurse is caring for a client diagnosed with coronary artery disease (CAD). What condition most commonly results in CAD?

atherosclerosis Atherosclerosis (plaque formation) is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug?

calcium-channel blocker Calcium-channel blocking agents may be used to treat CAD as well, although research has shown that they may be less beneficial than beta-adrenergic blocking agents. Diltiazem (Cardizem) is an example of a calcium-channel blocker.

A client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows:

elevated troponin levels. Troponin is present only in myocardial tissue; therefore, it is the gold standard for determining heart damage in the early stages of an MI. LDH1 and LDH2 may be elevated in response to cardiac or other organ damage during an MI. Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage during an MI

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client?

enhance myocardial oxygenation 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

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?

fatty deposits in the lumen of arteries 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.

The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse?

potassium level of 6 mEq/L Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L

The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client?

troponin This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but the studies are less specific indicators of myocardial damage than troponin.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse?

Altered level of consciousness A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately.

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. 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." Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness.

The nurse is teaching the client about coronary artery damage after an abnormal fasting lipid profile. The client asks the nurse what type of lipid is most troublesome. What is the nurse's bestresponse?

"The low-density lipoproteins (LDL) pose a threat to plague formation and can cause a heart attack of stroke." When there is an excess of LDL, these particles adhere to vulnerable points in the arterial endothelium. Here, macrophages ingest them, leading to the formation of foam cells and the beginning of plaque formation. A harmful effect is exerted on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining.

To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)?

60 minutes The 60-minute interval is known as "door-to-balloon time" in which a PTCA can be performed on a client with a diagnosed MI. The 30-minute interval is known as "door-to-needle time" for the administration of thrombolytics after MI.

The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration?

Count the respiratory rate for bradypnea. 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.

The nurse is caring for a client who is being evaluated for lipid-lowering medication. The client's laboratory results reveal the following: total cholesterol 230 mg/dL, LDL 120 mg/dL, triglyceride level 310 mg/dL. Which class of medications would be most appropriate for the client based on these laboratory findings?

Nicotinic acid The most appropriate class of medications based on the client's laboratory findings would be nicotinic acid. This class of medications is prescribed for clients with minimally elevated cholesterol and LDL levels or as an adjunct to a statin when the lipid goal has not been has not been achieved and triglyceride levels are elevated.

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 experieincing 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?

Nitroglycerin SL Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency.

A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI.

A client with a family history of coronary artery disease reports experiencing chest pain and palpitations during and after morning jogs. What would reduce the client's cardiac risk?

smoking cessation The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight.