Exam 1 PCC 244 - Clotting

Which client is most at risk for atrial fibrillation?

*A client 3 days post coronary artery bypass surgery Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurence after CABG (coronary artery bypass graft) surgery.

The patient's SVT returns after 30 minutes. What medication do you anticipate will be ordered for the patient?

*Adenosine (Adenocard) 6 mg IV The nurse should give the medication as ordered to include 6 mg IV over 1 to 3 seconds followed by 20 mL saline flush. It may be repeated in 1 to 2 minutes if necessary. The nurse should monitor the patient's heart rate and rhythm carefully after administration of the medication. Be sure to have the crash cart available because a short period of asystole is common after administration. Bradycardia and hypotension may also occur.

A client with myocardial ischemia is having frequent PVCs. Which medication will the nurse administer?

*Amiodarone (Cordarone) Lidocaine, a class IV antidysrhythmic, is the treatment of choice for frequent PVCs.

A patient with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction (LVEF) of 18%. To decrease the risk of complications from these conditions, what drug does the nurse anticipate giving?

*Anticoagulants Thrombus formation occurs in the heart when the chambers do not contract normally and empty completely. Both atrial fibrillation and very low left ventricular output (LVEF <20%) lead to thrombus formation, which is treated with anticoagulants to prevent the release of emboli into the circulation as well as antidysrhythmics or cardioversion to control atrial fibrillation.

A client is to receive a morning dose of Digoxin. Which finding, if present, would indicate that the medication should not be given?

*Apical Pulse of 52 You hold Digoxin for Apical heart rate less than 60.

A nurse assesses a patient who has just returned to a telemetry unit after having a coronary angiogram using the left femoral artery approach. The patient's baseline blood pressure during the procedure was 130/72 and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be experiencing a complication?

*Apical pulse 132 and irregular An apical pulse of 132 with an irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. A slight elevation of blood pressure could be related to pain at the incision site. Usually, pulses are palpable at +2, but without additional baseline data on the client's pulses, this warrants monitoring. A soft groin area where the puncture site is located is a normal finding. Ecchymosis (Bruising) does not indicate a complication.

A client's ECG tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse will take?

*Assess the client's airway, breathing and level of consciousness. The first action that the nurse should take when ventricular tachycardia is observed is to assess theclient's airway, breathing and level of consciousness. if the client is unconscious or has experienced respiratory arrest, defibrillation and CPR are begun.

Which is a priority intervention for the client experiencing atrial fibrillation?

*Assessing for shortness of breath A serious and frequent complication of atrial fibrillation is systemic emboli, particulary pulmonary emboli. The nurse should assess for shortness of breath, chest pain, and hemoptysis bcasue they are symptoms of pulmonary emboli.

What is most organ damage in hypertension related to?

*Atherosclerotic changes in vessels that supply the organs Elevated BP causes the entire inner lining of arterioles to become thickened from hyperplasia of connective tissues in the intima and affects coronary circulation, cerebral circulation, peripheral vessels, and renal and retinal blood vessels. The narrowed vessels lead to ischemia and ultimately to damage of these organs.

A patient with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?

*Blood pressure is 88/46 Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicated injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

A patient with hypertension is being treated with metoprolol (lopressor), hydrochlorothiazide (Hydrodiuril) and Captopril (Capoten). Other scheduled medications include docusate (colace) and a multivitamin. The patient's current blood pressure is 124/86 mmHg and pulse rate is 48. Which scheduled medications doses should the nurse administer?

*Captoril *Hydrochlorothiazide *Decusate *Multivitamin The correct answer is everything except Metoprolol. The patient's heart rate is bradycardic, and metoprolol, a beta blocker, decreases the heart rate. The captopril does not lower heart rate and may be safely administered to main control of hypertension. The hydrochlorothiazide does not lower the heart rate and may be safely administered to maintain control of hypertension. Docusate is a stool softener and may be safely administered to the client. Straining at stool could cause the patient to use the Valsalva maneuver, which could temporarily lower the heart rate further. A multivitamin would not adversely affect the client's pulse rate.

Priority Decision: A patient with stage 2 hypertension who is taking hydrochlorothiazide (HydroDiuril) and lisinopril (Prinivil) has prazosin (Minipress) added to the medication regimen. What is most important for the nurse to teach the patient to do?

*Change position slowly and avoid prolonged standing Prazosin is an α-adrenergic blocker that causes dilation of arterioles and veins and causes orthostatic hypotension. The patient may feel dizzy, weak, and faint when assuming an upright position after sitting or lying down and should be taught to change positions slowly, avoid standing for long periods, do leg exercises to increase venous return, and lie or sit down when dizziness occurs. Direct-acting vasodilators often cause fluid retention; dry mouth occurs with diuretic use, although orthostatic hypotension may occur with hydrochlorothiazide as well; and centrally acting α- and β-blockers may cause bradycardia.

A nurse is instructing a client diagnosed with coronary artery disease about care at home. The nurse determines that teaching is effective when the client states:

*If I have chest pain *I stop activity and place one nitroglycerine tablet under my tongue *I plan to avoid being around people when they are smoking *I plan on walking on most days of the week for at least 30 minutes. Stopping activity decreases the body's demand for oxygen. One nitroglycerin table, taken sublingually, dilates the coronary arteries and increases oxygen to the myocardium. If the pain is unrelieved, a second table should be taken 5 minutes later. Passive smoke can cause vasoconstriction and decrease blood flow velocity even in healthy young adults. The American Heart Association recommends exercising for 30 minutes on most days of the week. Medical attention is required only if pain persists and then the client should call 911 rather than the physician because emergency treatment may be necessary. Nitroglycerin loses it potency if stored in warm, moist areas, making the client's pants pocket an undesirable location for storage. If the pain is relieved after one table, another tablet is not required. The standard dose for nitroglycerin is one table or spray 5 minutes apart until the pain is relieved, to a maximum of three tables.

Two hours later, the patient is admitted to the cardiac step-down unit with orders for a saline lock, cardiac diet, and oxygen at 2 L per nasal cannula with follow-up cardiac enzymes, and 12-lead ECG in 6 hours. One hour later, the patient reports severe shortness of breath. His oxygen saturation has dropped to 88%, BP is 96/54, and his monitor shows sinus tachycardia with a rate of 114. He reports mild chest pain. What would be your priority action?

*Increase oxygen Based on the history of the recent CP and now increased shortness of breath with hypoxemia, the nurse can conclude that the patient may be experiencing an acute MI. Your priority action is to increase his oxygen to reduce demand on the heart. You would not administer a fluid bolus even though BP is low, that is not the priority issue. There is no indication that the patient is in pulmonary edema. You would want to reassess vital signs after you have addressed the low O2 Sats.

The nurse has administered a drug that causes vasoconstriction. Which finding indicates an expected response?

*Increased diastolic blood pressure Diastolic pressure is determined by the amount of vasoconstriction in the periphery. An increase in peripheral vasular resistance increases diastolic pressure.

The physician prescribes losartan (Cozaar) for a patient with hypertension. The nurse carrying out the order explains to the client that this medication promotes vasodilation by which action?

*Inhibiting conversion of a substance that would cause vasoconstriction. Losartan is an angiotensin II antagonist. Because angiotensin II is a powerful vasoconstrictor, this inhibition results in vasodilation and normalizing blood pressure. The patient should be assessed for dizziness, cough, and diarrhea while taking this medication.

At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be completed on the patient at 1400. Which action should the nurse initiate first?

*Initiate NPO (nothing per mouth) status for the patient Cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam (Versed) during the procedure. To avoid aspiration, the client should be NPO 6-12 hours prior to the procedure. Because of the time element, NPO status should be initiated first and then teaching should occur. A consent form should be signed after the cardiologist has spoken with the client, and then an IV infusion order would be received.

Which arteries are the major providers of coronary circulation?

*Left circumflex artery *Right Coronary artery *Left anterior descending artery The left circumflex and left anterior descending arteries branch from the left coronary artery. The left coronary artery and right coronary artery arise from the aorta to supply the atria, ventricles, and interventricular septum.

A patient with myocardial infarction is experiencing new, multiform, premature ventricular contractions (PVCs). The nurse checks the medication care to ensure that which medication is available for immediate use?

*Metoprolol (Lopressor)

While caring for a patient who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurses first course of action should be to:

*Notify the physician promptly PVCs are often a precursor of life-threatening arrhythmia's, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVC's occur at a rate greater than five or six per minute in the post-MI patient, the physician should be notified immediately. More than six PVC's per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as amiodarone. Increasing the IV infusion rate would not decrease the number of PVC's. Increasing the oxygen concentration should not be the nurses' first course of action: rather, that the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

The next morning, the patient is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery. Which procedure is most likely to be performed to correct this condition?

*PTCA with coronary artery stent placement The most common complication of PTCA is re-blockage of the coronary artery. For this reason, a coronary stent is placed to keep the re-opened artery from closing again.

Ten minutes later, the patient is still in SVT and reports substernal chest pain and dizziness. Which action will you expect the physician to take to treat the dysrhythmia?

*Perform carotid massage. The physician may perform vagal stimulation such as carotid massage, which may be successful in terminating the dysrhythmia; however, it may only be temporarily successful.

A diabetic patient newly diagnosed with hypertension also smokes. The nurse would question an order for which antihypertensive medication.

*Propranolol Adverse effects of beta-adrenergic blockers such as propranolol include their potential to cause broncho-spasm and to mask hypoglycemia attacks. Therefore the patients who are at risk for these conditions should not utilize beta-blockers as antihypertensive medications.

The SVT resolves immediately after IV adenosine (Adenocard) is administered. Because the patient has experienced repeated episodes of symptomatic SVT, a cardiologist has been consulted and treatment options discussed. What is the preferred treatment for recurrent SVT?

*Radio frequency catheter ablation If SVT is continuous, the patient should be studied in the electrophysiology laboratory. The preferred treatment is radiofrequency catheter ablation. Radiofrequency ablation is a procedure that can cure many types of fast heart rates. Using special wires or catheters that are threaded into the heart, radiofrequency energy (low-voltage, high-frequency electricity) is targeted toward the area(s) causing the abnormal heart rhythm, permanently damaging small areas of tissue with heat. The damaged tissue is no longer capable of generating or conducting electrical impulses. If the procedure is successful, this prevents the dysrhythmia from being generated, thereby curing the patient.

A client has chest pain rated an 8 on a 10 point scale. The 12 lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

*Reduce Pain and Myocardial oxygen demand Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

A nurse is caring for a client in the immediate post-cardiac catheterization period. Which interventions should the nurse include in the client's care?

*Restrict the client to bed rest for 2 to 6 hours *Assess the insertion site *Monitor vital signs every 15 minutes for the first hour The key word is "Immediate" In the immediate period, the client's vital signs are typically monitored every 15 minutes for the first hour, then every 30 minutes for 2 hours or until vital signs are stable. The pulses in the affected extremity are usually assessed with every vital signs. All peripheral pulses do not require assessment. Clients typically remain on bedrest for 2 to 6 hours unless a special closure is used. The insertion site extremity is kept straight following the procedure, so ROM exercises would not be performed.

Alteplase recombinant or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:

*Revascularize the blocked coronary artery The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm: nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.

Which dysrhythmia may develop in a client with frequent premature ventricular contractions?

*Ventricular tachycardia With an acute myocardial infraction (MI), the onset of PVCs may be considered as a warning that could hearld the onset of ventricular tachycardia or ventricular fibrillation.

Cardiac Conduction Pathway

1.Sinoatrial (SA) node 2.Right and left atrial cells 3.Internodal pathways 4.Atrioventricular (AV) node 5.Bundle of His 6.Right and Left bundle branches 7.Purkinje Fibers 8.Ventricular cells

A patient receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500ml. How many milliliters per hour will this patient receive? Put the whole number only.

24 mL/hr

Superior Vena Cava

Transports deoxygenated blood from upper body

Ventricular Tachycardia

Ventricular tachycardia: An abnormal heart rhythm that is rapid and regular and that originates from an area of the lower chamber (ventricle) of the heart. Ventricular tachycardias can be life-threatening arrhythmias that are commonly associated with damage to the heart muscle due to coronary artery disease.

Pulmonary Artery

Carries deoyxgenated blood from the right ventricle

Mitral Valve

Flap of tissue between the left atrium and left ventricle

Tricuspid Valve

Flap of tissue between the right atrium and ventricle

Purkinje fibers

Forms the last part of the heart conduction system

Internodal Pathways

Means for electrical currents to pass between nodes

Sinoatrial Node

Pacemaker of the heart

Depolarization

Reversal of positive and negative charges

Pericardium

Sac surrounding the heart and base of great vessels

Coronary Arteries

Supplies oxygen and nutrients to the cardiac muscle

The nurse observes a prominent U wave on the clients ECG tracing. What is the nurse's interpretation of this finding?

The client may have a potassium imbalance. *A prominent U waves may be the result of hypokalemia.

A 45-year-old patient with stage 3 heart failure, a 1-month history of frequent episodes of ventricular tachycardia, and an ejection fraction less than 35% is returned from the OR after implantation of an ICD (implantable cardioverter-defibrillator). The patient was unsure about getting the device and hesitantly signed the consent form. For 3 hours after admission to ICU, his vital signs are stable, and ECG monitoring shows normal sinus rhythm. The patient suddenly develops pulseless ventricular tachycardia, codes, and receives 45 minutes of resuscitation efforts with no improvement. Given that the ICD did not operate during a sustained period of ventricular tachycardia, what step(s) should the nurse caring for this patient take now?

*Complete an incident report and notify administration This question illustrates the nurse's competency for systems thinking. Systems thinking is displayed as the nurse makes a connection between the insertion of an ICD, its malfunction, regulatory requirements related to the incident, and impact on the facility. FDA regulations require manufacturers and hospitals to report all pacemaker and ICD malfunctions, especially those that result in death or surgery. Failure to communicate this device problem may lead to underreporting of their potential defects. Between 1990 and 2002, the average rate of ICD device malfunction was 20.7 per 1000 new implants. Option A reflects an expanded concern that includes effects on the facility but does not approach the still wider repercussions of this scenario on the safety of numerous patients with ICDs. Providing emotional support to the family is an obvious and immediate concern but neglects recognition of the system effects of this incident. There is no evidence that indicates staff need instruction regarding ICD malfunctions, so that option is inappropriate at this time.

The patient is admitted to the emergency department after complaining of acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate the doctor would order to evaluate myocardial ischemia?

*Creatine kinase (CK), Myoglobin, Troponin T and Toponin I Although there is no single ideal test to diagnose MI, the most common laboratory tests include troponins T and I, creatine kinase-MB (CK-MB), and myoglobin. These cardiac markers are specific for MI and cardiac necrosis. Troponins T and I and myoglobin rise quickly. CK-MB is the most specific marker for MI but does not peak until about 24 hours after the onset of pain Hemoglobin, HCT, serum glucose, and BUN levels do not provide specific information related to myocardial ischemia.

The client is being given a drug that blocks the action of the sympathetic nervous system. Which assessment finding does the nurse expect?

*Decreased Heart Rate The sympathetic nervous system directly stimulates the ventricles, increasing heart rate. It also causes vasoconstriction, increasing blood pressure. Agents that block sympathetic impulses decrease heart rate and blood pressure.

The nurse hears the alarm sound on the telemetry monitor, quickly looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room, and on reaching the client's bedside, the nurse should perform which action first?

*Determine unresponsiveness Determining unresponsiveness is the first action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. A patient can have V-tach with and without a pulse. Checking for unresponsiveness determines if the client is affected by the decreased cardiac output. If the client is unresponsive the nurse proceeds through CAB— compressions, airway, breathing—of the cardiopulmonary resuscitation (CPR) sequence, remembering that the nurse should collect data before taking an action.

You immediately notify the provider and within 45 minutes, the patient is transferred to the CCU for close monitoring. He is in serious condition and has developed crackles bilaterally, and his chest pain level has increased. What medications do you anticipate will be ordered for this patient?

*Furosemide (Lasix) *Atenolol (Tenormin) *Morphine Based on the assessment findings, several medications will be ordered including IV diuretics (furosemide) and supplemental oxygen. If congestion and shortness of breath become critical, the patient may need to be placed on a ventilator until the fluid volume overload is under control. Once-a-day beta-adrenergic blocking agents (atenolol) decrease the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with MI. A cardioselective beta-blocking agent is usually prescribed within the first 1 to 2 hours after an MI if the patient is hemodynamically stable. Beta blockers slow the heart rate and decrease the force of cardiac contraction. Medical interventions aim to relieve pain and decrease myocardial oxygen requirements through preload and afterload reduction. IV morphine is used to decrease pulmonary congestion and relieve pain.

The nurse is discharging to home a client with a new diagnosis of atrial fibrillation. The nurse explains that the onset of which symptoms is most important to report to the physician?

*Hemoptysis Chest pain, dyspnea, and hemoptysis are common symptoms of pulmonary embolism and any of these would be important to report immediately. Patients in Atrial Fibrillation have higher tendency to throw a clot. Irregular pulse is expected with atrial fibrillation. Fiver is not associated with atrial fibrillation and is not necessarily included in discharge teaching. However, it could be a sign of illness that could increase the workload of the heart, and therefore it would be second-most important item to report if it occurred. Fatigue may accompany atrial fibrillation in some individuals.

A nurse is caring for a client with chronic atrial fibrillation who is at risk for systemic emboli. Which drug should the nurse expect to administer to prevent this complication?

*Heparin Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin.

Atrial Fibrillation

Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications.

Atrial Flutter

Atrial flutter: Well-organized but overly rapid contractions of the atrium of the heart (usually at a rate of 250-350 contractions per minute). Flutter refers to a rapid vibration or pulsation. The difference between flutter and fibrillation is that flutter is well organized while fibrillation is not.