Iggy Study Guide Ch. 35: Critical Care of Patients with Acute Coronary Syndromes

How soon does the nurse expect anginal pain to begin subsiding after administering sublingual nitroglycerin to a client with chronic stable angina? A. 1-2 minutes B. 5-6 minutes C. 10-12 minutes D. 15-20 minutes

A After administering SL NTG, the nurse expects the client's anginal pain to begin subsiding within 1 to 2 minutes and pain relief should be evident in 3 to 5 minutes. If the client is experiencing some but not complete relief and vital signs remain stable, another NTG tablet or spray may be used. In 5-minute increments, a total of three doses may be administered in an attempt to relieve anginal pain. Angina usually responds to NTG. The client typically states that the pain is relieved or markedly diminished. When simple measures such as taking three sublingual nitroglycerin tablets, in times increments, one after the other do not relieve chest discomfort, the client may be experiencing an MI.

How would the critical care nurse assess for postoperative bleeding in a client who just had CABG surgery? A. Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage amount over 150 mL/hr to the surgeon. B. Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amount over 50 mL/hr to the surgeon. C. Assess the sternal dressing for bleeding every 4 hours, then reinforce with sterile gauze as needed and report the appropriate amount of bleeding to the surgeon. D. Assess the vein donor site every 4 hours and report the amount of serous drainage as well as pain to the surgeon.

A Bleeding after CABG surgery occurs to a limited extent in all clients. Measure mediastinal and pleural chest tube drainage at least hourly. Report drainage amounts over 150 mL/hr to the surgeon.

Which finding would the nurse expect when a client experiences a non-ST-segment elevation MI (NSTEMI)? A. ST depression and T-wave inversion on a 12-lead ECG B. Cardiac dysrhythmias C. Immediate elevation of troponin levels D. ST elevation in two contiguous leads on a 12-lead ECG

A Clients with NSTEMI present with ST segment and T-wave changes on a 12-lead ECG. These changes include ST depression and T-wave inversion, which indicate myocardial ischemia. Initially troponin level may be normal, but it elevates over the next 3 to 12 hours (not immediately). ST elevation in two contiguous leads on a 12-lead ECG is characteristic of STEMI. Dysrhythmias may occur with any MI and are not specific to NSTEMI.

Which statement by a client indicates to the nurse correct understanding of resuming sexual activity in the presence of angina? A. "When I can climb two flights of stairs, it is safe to resume sexual activity." B. "It is best to resume sexual activity in the evening before I go to sleep." C. "If I am unable to walk at least a mile, it is unsafe for me to resume sexual activity." D. "I will discuss alternative methods with my partner as I will no longer be able to resume my previous level of sexual activity."

A In general, a client who can walk one block or climb two flights of stairs without symptoms can usually safely resume sexual activity. Clients can resume sexual intercourse on the advice of the cardiac health care provider, usually after an exercise-tolerance assessment. Suggest that initially clients have intercourse after a period of rest.

Which manifestation would the nurse expect with a client labeled class I on the Killip scale for heart failure? A. Clear lung sounds and absence of S3 B. Crackles in the lower half of the lung fields and possible S3 C. Crackles more than halfway up the lung fields and frothy sputum D. Systolic blood pressure less than 90 mm Hg and oliguria

A The classic Killip system identifies four classes of heart failure based on prognosis. The class I description includes absence of crackles and S3.

Which findings would the nurse expect when assessing a client with chronic stable angina? Select all the apply. A. Chest discomfort occurs in a pattern that is familiar to the client B. Chest discomfort that occurs with moderate to prolonged exertion C. Frequency, duration, and intensity of symptoms remain the same over several months D. Results in moderate limitation of activity E. Usually treated with rest and nitroglycerin (NTG) F. Pain lasts less than 15 minutes

A, B, C, E, F All of these characteristics describe chronic stable angina, expect that this condition results in only slight limitation of activity (not moderate).

Which statements about coronary artery disease and women are accurate? Select all that apply. A. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men. B. Women have smaller coronary arteries and frequently have plaque that breaks off and travels into the small vessels to form an embolus. C. The older a woman is the more likely she is to have coronary artery disease. D. More men than women die within a year after a MI. E. Women whose parents had CAD are more susceptible to the disease. F. Many women experience atypical angina as indigestion, pain between shoulders, aching jaw, and a choking sensation.

A, B, C, E, F All of these statements are accurate except that more women than men die within a year after a myocardial infarction.

For which manifestations would the nurse monitor when providing care for a client prescribed beta-blocker therapy? Select all that apply. A. Depression B. Bradycardia C. Decreased level of consciousness D. Increased urine output E. Crackles or wheezes in the lungs F. Chest discomfort

A, B, C, E, F During beta-blocker therapy, monitor for: bradycardia; hypotension; decreased level of consciousness (LOC); and chest discomfort. Assess the lungs for crackles (indicative of heart failure) and wheezes (indicative of bronchospasm). Hypoglycemia, depression, nightmares, and forgetfulness are also problems with beta blockade, especially in older clients.

Which alternative therapies may be helpful in reducing a client's anxiety about progressive activity postoperatively and during rehabilitation? Select all that apply. A. Guided imagery B. Progressive muscle relaxation C. Acupuncture D. Music therapy E. Pet therapy F. Herbal remedies

A, B, D, E Additional therapies can aid in reducing the client's anxiety about progressive activity both in the immediate postoperative period and during the rehabilitation phase. Techniques such as progressive muscle relaxation, guided imagery, music therapy, pet therapy, and therapeutic touch may decrease anxiety, reduce depression, and increase adherence with activity and exercise regimens after heart surgery.

Which signs and symptoms indicate to the nurse that a client with a myocardial infarction and heart failure is going into cardiogenic shock? Select all that apply. A. Cold, clammy skin with poor peripheral pulses B. Pulmonary congestion and tachypnea C. Bradycardia and hypertension D. Urine output less than 0.5 to 1 mL/kg/hr E. Agitation, restlessness, or confusion F. Systolic BP less than 100 mm Hg

A, B, D, E Manifestations of cardiogenic shock include: tachycardia; hypotension; systolic BP less than 90 mm Hg or 30 mm Hg less than the client's baseline; urine output less than 0.5-1 mL/kg/hr; cold, clammy skin with poor peripheral pulses; agitation, restlessness or confusion; pulmonary congestion; tachypnea; and continuing chest discomfort. The nurse would document and report these immediately because undiagnosed cardiogenic shock has very high mortality.

Which statements about the use of thrombolytic agents for a client with an acute myocardial infarction are accurate? Select all that apply. A. Clients who cannot receive a thrombolytic agent must be carefully monitored before, during, and after the drug is given. B. A client who has received a thrombolytic agent must be carefully monitored before, during, and after the drug is given. C. Thrombolytic therapy is indicated for chest pain of less than 15 minutes duration that is relieved by nitroglycerin. D. The client must be assessed for absolute and relative contraindications before a thrombolytic agent is administered. E. Monitor for bleeding which is a major risk when a client receives thrombolytic therapy. F. Indications that the clot has been dissolved and the artery reperfused include sudden onset of ventricular dysrhythmias.

A, B, D, E, F All of the statements about thrombolytic therapy are accurate except option C. A client with chest pain lasting less than 15 minutes that is relieved by nitroglycerin is most likely experiencing chronic stable angina which is not treated with thrombolytics.

Which are characteristics the nurse would expect to find in a client with unstable angina (USA)? Select all that apply. A. Chest pain occurs at rest or with exertion B. Pain causes severe limitation of activities C. Includes chronic stable angina, vasospastic angina, and new-onset angina D. Presents with ECG changes and elevation of troponin levels E. Ischemia does not cause myocardial damage or cell death F. The pain or pressure is poorly relieved by nitroglycerin

A, B, E, F Unstable angina may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerin. Unstable angina includes new-onset angina, vasospastic angina, and pre-infarction angina. Clients with unstable angina may present with ST segment changes on a 12-lead ECG but do not have changes in troponin levels. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death.

Which absolute contraindications would the nurse assess for when a client is being considered for thrombolyti therapy? Select all that apply. A. Any prior intracranial hemorrhage B. History of chronic, severe, poorly controlled hypertsion C. Suspected aortic dissection D. Known malignant intracranial neoplasm (primary or metastatic) E. Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg) F. Active bleeding or bleeding diathesis (excluding menses)

A, C, D, F Absolute contraindications to thrombolytic therapy include: any prior intracranial hemorrhage; known structural cerebral vascular lesion (e.g., arteriovenous malformations); known malignant intracranial neoplasm (primary or metastatic); ischemic stroke within 3 months except acute ischemic stroke within 3 hours; suspected aortic dissection; active bleeding or bleeding diathesis (excluding menses); and significant closed-head or facial trauma within 3 months. Relative contraindications include: history of chronic, severe, poorly controlled hypertension and severe uncontrolled hypertension on presentation (SBP>180 mm Hg). See Table 35.4 in the text for additional relative contraindications.

Which clients are potential candidates for coronary artery bypass graft (CABG) surgery? Select all that apply. A. Client with angina and greater than 50% occlusion of the left main coronary artery that cannot be stented. B. Client with unstable angina with moderate one-vessel disease appropriate for stenting C. Client with valvular disease D. Client with coronary vessels unsuitable for percutaneous coronary intervention (PCI) E. Client with acute myocardial infarction (MI) that is responding to medical therapy F. Client with ischemia or impending MI after angiography or PCI

A, C, D, F Candidates for CABG surgery are clients who have: angina with greater than 50% occlusion of the left main coronary artery that cannot be stented; unstable angina with severe two-vessel disease, moderate three-vessel disease, or small-vessel disease in which stents could not be introduced; ischemia with heart failure; acute MI with cardiogenic shock; signs of ischemia or impending MI after angiography or percutaneous coronary intervention; valvular disease; and coronary vessels unsuitable for percutaneous coronary intervention (PCI).

Which essential preoperative teaching would the nurse provide to a client scheduled for CABG surgery using the traditional procedure? Select all that apply. A. There will be a sternal incision. B. Coughing will be avoided to keep stress off of the sternal incision. C. There will be as many as three chest tubes in place after the surgery. D. An indwelling urinary catheter will be in place to drain urine. E. You will be on bedrest for up to 48 hours after the surgery. F. An endotracheal tube will prevent talking immediately after surgery.

A, C, D, F For the traditional surgical procedure, explain that the client will have a sternal incision and possible a large leg incision also; one, two, or three chest tubes; an indwelling urinary catheter; pacemaker wires; and invasive hemodynamic monitoring. An endotracheal tube will be connected to a ventilator during surgery. The endotracheal tube is removed as soon as the client is awake and stable. Tell the client and family that the client will not be able to talk while the endotracheal tube is in place. Two hours after extubation (removal of the endotracheal tube), clients should be dangled at the bedside as tolerated and turned side to side. Within 4 to 8 hours after extubation, help clients out of bed into a chair. By the first day after surgery, they should be out of bed in a chair and ambulating 25 to 100 feet three times a day as tolerated. Encourage the client to splint, cough, turn, and deep breathe to expectorate secretions.

Which essential points would the nurse include when teaching a client with coronary artery disease how to manage activity at home? Select all that apply. A. Begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day. B. Check your pulse before and after you exercise. C. Always carry a bottle of nitroglycerin with you. D. Stop your activity if your pulse increases by 10 beats/min. E. Exercise outdoors when the weather is pleasant. F. Avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements).

A, C, E, F Teaching about activities at home for clients with CAD would include: begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day; carry nitroglycerin with you; check your pulse before, during, and after the exercise: stop the activity for a pulse increase of more than 20 beats/min, shortness of breath, angina, or dizziness; make gradual increases in walking distance; exercise outdoors when the weather is good; after an exercise tolerance test and with your health care provider's approval, walk at least three times each week, increasing the distance every other week, until the total distance is 1 mile; and avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements).

Which are post-administration nursing responsibilites when caring for a client who received thrombolytic therapy? Select all that apply. A. Observe all IV sites for bleeding and patency. B. Document the client's emotional reaction to the thrombolytic therapy. C. Monitor white blood cells (WBC) count and differential. D. Test stool, urine, and emesis for occult blood. E. Monitor clotting study values. F. Observe for signs of internal bleeding (e.g., blood pressure)

A, D, E, F During and after thrombolytic administration, immediately report any indications of bleeding to the cardiac health care provider or Rapid Response Team. Observe for signs of bleeding by: documenting the client's neurologic status (in case of intracranial bleeding); observing all IV sites for bleeding and patency; monitoring clotting studies; observing for signs of internal bleeding (monitor hemoglobin, hematocrit, and blood pressure); and testing stools, urine, and emesis for occult blood.

Which indicators of metabolic syndrome would the nurse expect in a client with heart failure? Select all that apply. A. Blood pressure of 130/86 mm Hg while taking a beta blocker B. Large waist of 35 inches (88 cm) or greater for men C. HDL-C greater than 40 mg/dL for men D. Increased fasting glucose of 100 mg/dL or higher E. Increased level of triglycerides of 150 mg/dL or higher F. Decreased LDL-C of less than 50 mg/dL for women

A, D, E, F Indicators of metabolic syndrome include: blood pressure of 130/85 mm Hg or higher or taking antihypertensive drug(s); HDL-C <40 mg/dL for men or <50 mg/dL for women or taking a cholesterol lowering drug; triglycerides of 150 mg/dL or higher or taking a cholesterol lowering drug; fasting glucose of 100 mg/dL or higher or taking antidiabetic drug(s); and large waist size (excessive abdominal fat causing central obesity) of 40 inches (102 cm) or greater for men or 35 inches (88 cm) or greater for women.

Which statement by the client who had CABG surgery indicates to the nurse that his or her pain is related to the sternotomy and is not anginal in origin? A. "The pain goes down my arm and sometimes into my jaw." B. "My pain increases when I cough or take a deep breath." C. "The nitroglycerin helped to relieve the pain." D. "I feel nausea and shortness of breath with the pain."

B After CABG, the nurse must distinguish between sternal and anginal pain. Typical sternotomy pain is localized, does not radiate, and often become worse when the client coughs or breaths deeply. He or she may describe the pain as sharp, aching, or burning. Pain may stimulate the sympathetic nervous system, which increases the heart rate and vascular resistance while decreasing cardiac output. Administer enough of the prescribed analgesic in adequate doses to control pain. Option A, C, and D are descriptors of anginal pain.

After administering SL nitroglycerin to a client whose baseline blood pressure is 130/80 mm Hg, for which finding would the nurse immediately notify the health care provider? A. Client reports a headache. B. Systolic pressure is 90 mm Hg. C. Anginal pain is somewhat relieved. D. Heart rate is 92 beats/min.

B After adminstering SL NTG to a client, if the blood pressure (BP) is less than 100 mg Hg systolic or 25 mm Hg lower than the previous reading, lower the head of the bed and notify the cardiac health care provider. If the client is experiencing some, but not complete, relief and vital signs remain stable, another NTG tablet or spray may be used. In 5-minute increments, a total of three doses may be administered in an attempt to relieve anginal pain.

Which task would the nurse delegate to the assistive personnel (AP) when caring for a client in phase 1 of cardiac rehabilitation? A. Assist the client to ambulate 400 feet four times a day. B. Assist the client with ambulation to the bathroom. C. Assess the client's vital signs and fatigue level with each increase in activity. D. Teach the client to notify the health care provider for episodes of chest pain.

B Cardiac rehabilitation is the process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 1 begins with the acute illness and ends with discharge from the hospital. Assisting with ambulation is also acceptable, but distractor A suggests the client walk farther and more often than is appropriate for phase 1 of cardiac rehabilitation. Assessing and teaching require additional training and are within the scope of the professional RN.

Which procedure would the nurse expect to be recommended for a client with discrete, proximal, noncalcified blockage in one coronary artery? A. Minimally invasive direct coronary artery bypass (MIDCAB) B. Percutaneous coronary intervention (PCI) C. Immediate thrombolytic reperfusion therapy D. Exercise tolerance test (stress test) on a treadmill

B Clients who are most likely to benefit from PCI have single- or double-vessel disease with discrete, proximal, noncalcified lesions or clots.

Which procedure has shown promise for managing clients with cardiogenic shock? A. Percutaneous ventricular assistive device B. Immediate reperfusion C. Intra-aortic balloon pump D. Minimally invasive bypass surgery

B Immediate reperfusion is an invasive intervention that shows some promise for managing cardiogenic shock. The client is taken to the cardiac catheterization laboratory, and an emergency left-sided heart catheterization is performed. If the client has a treatable occlusion or occlusions, the interventional cardiologist performs a PCI in the catheterization laboratory, or the client is transferred to the operating suite for a coronary artery bypass graft (CABG).

What is the best action for the home health nurse to take when visiting a new client with CAD who is experiencing new-onset chest pain and shortness or breath? A. Instruct the client to rest quietly and take slow, deep breaths. B. Have the client chew a 325-mg aspirin tablet and call 911. C. Apply supplemental home oxygen until the symptoms subside. D. Administer a sublingual nitroglycerin tablet and have the family take the client to the emergency room.

B New-onset angina is a form of unstable angina. Clients with unstable angina may present with ST segment changes on a 12-lead ECG but do not have changes in troponin levels. Ischemia is present but is not severe enough to cause detectable myocardial damage or cell death. If the client has new-onset angina at home, he or she should chew aspirin 325 mg (four "baby aspirins" that are 81 mg each) immediately and call 911!

The nurse would teach a client to seek treatment for symptoms of myocardial infarction (MI) immediately rather than delay, because physical changes occurs in how many hours after an MI? A. 3 hours B. 6 hours C. 12 hours D. 24 hours

B Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted region appears blue and swollen. These changes explain the need for intervention within the first 4 to 6 hours of symptom onset!

An alert and oriented client comes to the walk-in clinic with left-sided chest pain, mild shortness of breath, and diaphoresis. What is the nurse's first priority action? A. Obtain a complete cardiac history for the client. B. Place the client in semi-Fowler position with supplemental oxygen. C. Instruct the client to go immediately to the nearest full-service hospital. D. Immediately alert the health care provider and establish IV access.

B The client is likely experiencing an imbalance between oxygen supply and myocardial oxygen demand. Administering supplemental oxygen will help to correct this imbalance and relieve the chest pain symptoms. The nurse would also notify the health care provider, establish IV access, and get a cardiac history, but the first priority would be to supply oxygen to the myocardium. The nurse would not instruct the client to go elsewhere, but with input from the health care provider might call EMS to transport the client to an emergency department is he or she were stable.

Which type of dysrhythmia would the nurse expect to monitor for when a client experiences an inferior wall myocardial infarction (IWMI)? A. Premature ventricular complexes (PVCs) B. Bradycardia with second-degree heart block C. Supraventricular tachycardia D. Atrial fibrillation

B Typical dysrhythmias for the client with an inferior ACS (includes IWMI) are bradycardias and second-degree atrioventricular (AV) blocks resulting from ischemia of the AV node. These rhythms tend to be intermittent. Monitor the cardiac rhythm and rate and the hemodynamic status. If the client becomes hemodynamically unstable, a temporary pacemaker may be necessary.

Which observation would the nurse expect when a client develops mediastinitis after CABG surgery? Select all that apply. A. Anginal-type chest pain B. Fever continuing beyond the first 4 days after surgery C. Bogginess of the sternum D. Redness and drainage from the suture site E. Induration or swelling at the suture site F. Decreased white blood cell count

B, C, D, E After CABG surgery, the nurse would be alert for mediastinitis (infection of the mediastinum) by observing for: fever continuing beyond the first 4 days after CABG; instability (bogginess) of the sternum; redness, induration, swelling, or drainage from suture sites; and an increased white blood cell count (not decreased).

A client with chronic stable angina now has chest pressure, cool and clammy skin, blood pressure 150/90 mm Hg, heart rate 100 beats/min, and respiratory rate 32 breaths/min. What are the priorities of collaborative care for this client? Select all that apply. A. Maintain NPO status B. Relieve chest pain C. Improve coronary artery perfusion D. Draw troponin blood samples E. Improve myocardial oxygenation F. Relieve nausea

B, C, D, E This client has experienced a change from chronic stable angina to symptoms that may indicate acute coronary syndrome. The purpose of collaborative care is to decrease pain, decrease myocardial oxygen demand, and increase perfusion (myocardial oxygen supply). Emergency care of the client with chest discomfort includes: assess airway, breathing, and circulation (ABCs); defibrillate as needed; provide continous ECG monitoring; obtain the client's description of pain or discomfort; obtain the client's vital signs (blood pressure, pulse, respiration); assess/provide vascular access; consult chest pain protocol or notify the cardiac health care provider or Rapid Response Team for specific intervention; obtain a 12-lead ECG within 10 minutes of report of chest pain; provide pain relief medication and aspirin (non-enteric coated) as prescribed; administer supplemental oxygen therapy to maintain oxygen saturation > 90%; remain calm and stay with the client if possible; assess the client's vital sings and intensity of pain 5 minutes after administration of medication; remedicate with prescribed drugs (if vital signs remain stable) and check the client every 5 minutes; and notify the cardiac health care provider if vital signs deteriorate. Troponin levels would be sent to the laboratory to check for possible MI.

Which postprocedure medications would the nurse teach about, before discharge, to a client who had a percutaneous coronary intervention (PCI)? Select all that apply. A. Furosemide B. Clopidogrel C. Metoprolol D. Isosorbide dinitrate E. Docusate F. Aspirin

B, C, D, F Clients who undergo PCI are required to take dual antiplatelet therapy (DAPT) consisting of aspirin and platelet inhibitor. The health care provider also prescribes a long-term nitrate and beta blocker. An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is added for clients who had primary angioplasty after an MI.

Which interventions would the nurse perform to protect a client from a sternal wound infection after CABG surgery? Select all that apply. A. Shave the client's body from neck to knees. B. Instruct the client to shower with 4% chlorhexidine gluconate. C. Prepare the surgical site by clipping hair when applying chlorhexidine with isopropyl alcohol (0.5% or 2%). D. Collect and send urine and sputum samples to the laboratory for culture and sensitivity. E. Administer IV antibiotics 1 hours prior to the surgical procedure. F. Wear gloves, a gown, and a mask while preparing the client for surgery.

B, C, E To decrease risk of a sternal wound infection, the nurse would have the client shower with 4% chlorhexidine gluconate (CHG). This decreases the number of microorganisms on the skin. Surgical sites are prepared with slipping hair and applying CHG with isopropyl alcohol (either 0.5% or 2%). In addition, IV antibiotics are administered 1 hour before the surgical procedure. Research suggests that shaving a client's skin before surgery may raise the risk of an infection; thus, shaving a client's body may not protect against infection nor would sending lab specimens or wearing protective equipment.

Which advantages would the nurse teach a client about with regard to robotic heart surgery? Select all that apply. A. Shorter surgical time than traditional CABG surgery B. Shorter hospital stay of just 2 to 3 days C. Decreased pain due to smaller incisions D. Shorter time on the heart-lung bypass machine E. Chest tubes are never needed F. Ability to reach otherwise inaccessible blockage sites

B, C, F Robotic heart surgery is a step toward less invasive open-heart surgery. Surgeons operate endoscopically through very small incisions in the chest wall. Other advantages of robotic procedures include shorter hospital stays (average stay is 2 to 3 days), less pain because of small incisions, no need for heart-lung bypass machine, less anxiety for the client, and greater client acceptance, as well as increased ability to reach otherwise inaccessible blockage sites.

What diagnostic tests would the nurse obtain to determine whether a client admitted with acute-onset chest pain and dyspnea had experienced a myocardial infarction (MI)? Select all that apply. A. C-reactive protein B. 12-lead ECG C. Chest x-ray D. Serial troponins T and I E. Lipid profile F. Exercise stress test

B, D Troponin is specific for MI and cardiac necrosis. Twelve-lead ECGs allow the health care provider to examine the heart from varying perspectives. By identifying the lead(s) in which ECG changes are occurring, the health care provider can identify both the occurence and the location of ischemia (angina) or necrosis (infarction). Chest x-ray would be useful to rule out aortic aortic dissection, but not diagnose MI. C-reactive protein increases with inflammation or infection. If may rise after MI but is not diagnostic. Elevated lipids are a risk factor but do not diagnose MI. An exercise tolerance test (stress test) on a treadmill is used to assess for ECG changes consistent with ischemia, evaluate medical therapy, and identify those who might benefit from invasive therapy.

Which essential points would the nurse include when teaching a client with angina about nitroglycerin tablets? Select all that apply. A. If one tablet does not relieve the chest pain after 5 minutes, put two pills under your tongue. B. Keep your nitroglycerin pills with you at all times. C. The prescription should last about 7 to 8 months before a refill is needed. D. You can tell the tablets are active when you feel a tingling after placing one under your tongue. E. Keep the tablets in a glass, light-resistant container. F. If no immediate pain relief occurs, just wait because the drug will eventually take effect.

B, D, E Teach the client to carry NTG at all times. Keep the tablets in a glass, light-resistant container because the drug degrades quickly in light, moisture, and in plastic. The drug should be replaced every 3 to 5 months before it loses its potency or stops producing a tingling sensation when placed under the tongue. Management of chest pain at home includes: keep fresh nitroglycerin available for immedite use; at the first indication of chest discomfort, cease activity and sit or lie down; place one nitroglycerin tablet under your tongue, allowing the tablet to dissolve; wait 5 minutes for relief; if no relief results, call 911 for transportation to a health care facility; while waiting for emergency medical services (EMS), repeat the nitroglycerin and wait 5 more minutes; if there is no relief, repeat and wait 5 more minutes. Be sure to carry a medical identification card or wear a bracelet or necklace that identifies a history of heart problems.

What priority action will the nurse take when providing care for a client with chest pain being treated with IV nitroglycerin? A. Restrict the client to bedrest with use of a bedpan. B. Elevated the head of the bed to 90 degrees. C. Monitor blood pressure continuously. D. Increase the dose rapidly to achieve pain relief.

C A serious side effect of nitroglycerin is hypotension, so it is essential that any client receiving this drug by the IV route be continuously monitored for blood pressure. Research has shown that use of bedpans is more stressful to the hart than use of a beside commode. Elevating the head of the bad at 90 degrees may not be a comfortable position for the client. Increasing the dose too rapidly could lead to hypotension.

Which finding prompts the nurse to immediately contact the surgeon for a client who had a minimally invasive direct coronary artery bypass (MIDCAB)? A. Client has difficulty with coughing and deep breathing. B. Client has acute incisional pain. C. Client has ECG changes including Q waves and ST-segment and T-wave changes in leads V2 to V6. D. Client has chest tube drainage of 80 mL/hr.

C After MIDCAB surgery, the nurse assesses for chest pain and ECG changes (Q waves and ST-segment and T-wave changes in leads V2 to V6) because occlusion of the internal mammary artery (IMA) graft occurs acutely in only a small percentage of clients. If there is any question of acute graft closure, immediately notify the surgeon.

For which complication does the nurse monitor when a client with chronic stable angina (CSA) is prescribed a calcium channel blocker? A. Tachycardia B. Wheezes and crackles C. Hypotension D. Forgetfulness

C Calcium channel blockers are prescribed for clients with chronic stable angina to promote vasodilation and myocardial perfusion. The client would be monitored for hypotension because of the vasodilation effect.

What is the nurse's next action 5 minutes after administering a sublingual (SL) nitroglycerin tablet to a client with chest pain? A. Apply oxygen at 2 to 4 L by nasal cannula. B. Administer morphine sulfate IV push. C. Recheck pain intensity and vital signs. D. Notify the health care provider and give a chewable aspirin.

C Five minutes after administering a sublingual nitroglycerin tablet, the nurse would check the client's pain level and check his or her blood pressure.

Which nursing assessment is specific to a client who had CABG surgery with the radial artery used as the graft? A. Check the fingertips, hand, and arm for sensation and mobility once a shift. B. Take blood pressure every hour on the unaffected arm to use a leg cuff on the legs. C. Assess hand color, temperature, ulnar pulse, and capillary refill every hour initially. D. Assess for and document expected edema, bleeding, and swelling at the donor site.

C Monitor the neurovascular status of the donor arm of clients whose radial artery was used as a graft in CABG (usually the nondominant arm is used). Assess the hand color, temperature, pulse (both ulnar and radial), and capillary refill every hour initially. In addition, check the fingertips, hand, and arm for sensation and mobility at least every 4 hours (not once a shift).

Because many sudden cardiac arrest victims die before reaching the hospital, which priority teaching point would the nurse be sure to include in a community presentation about heart disease? A. The importance of controlling alcohol consumption and smoking cessation. B. Modifying risk factors and blood pressure medication compliance C. How to operate an automatic external defibrillator (AED) in the workplace D. Recognizing unstable angina and when to call for help

C Ninety percent of sudden cardiac arrest victims die before reaching the hospital and many of these deaths are attributed to ventricular fibrillation (v fib). To help combat this problem, automatic external defibrillators (AEDs) are found in many public places, such as workplaces, shopping centers, and on airplanes. Employees are taught how to use these devices if a sudden cardiac arrest occurs.

Which drug therapy would the nurse expect to be prescribed for a client with acute coronary syndrome (ACS) to decrease the risk of recurrent myocardial infarction, stroke, and mortality? A. Anti-inflammatory drug B. Central vasodilator C. High-intensity statin therapy D. Anticoagulant therapy

C Statin therapy reduces the risk of developing recurrent MI, mortality, and stroke. Before discharge, all clients diagnosed with ACS should be started on high-intensity statin therapy despite results of lipid panel testing. High-intensity statins include atorvastatin 80 mg and rosuvastatin 20 mg to 40 mg daily.

Following CABG surgery, a client's body temperature is below 96.8 degree F. What measures would the nurse take to rewarm the client? A. Infuse warm IV fluids. B. Do not rewarm because cold cardioplegia is protective. C. Place the client in a warm fluid bath. D. Use lights and thermal blankets to slowly warm the client.

D Hypothermia is a common problem after CABG surgery. Although warm cardioplegia is now the usual operative procedure used, it is not uncommon for the body temperature to drift downward after the client leaves the surgical suite. Monitor the body temperature and institute rewarming procedures if the temperature drops below 96.8 degrees F. Rewarming may be accomplished with warm blankets, lights, or thermal blankets. The danger of rewarming clients too quickly is that they may begin shivering, resulting in metabolic acidosis, increased myocardial oxygen consumption, and hypoxia.

Which assessment would the nurse perform to help prevent harm from graft collapse after CABG surgery? A. Assess for motion and sensation in the donor extremity. B. Observe for generalized hypothermia. C. Auscultate lungs for crackles or wheezes. D. Monitor blood pressure for hypotension.

D The nurse would monitor for hypotension (systolic BP<90 mm Hg) which is a major problem because it may result in the collapse of the coronary graft. Decreased preload can result from hypovolemia or vasodilation. If the client is hypovolemic, it might be appropraite to increase fluid aministration or administer blood. The cardiac health care provider may manage the client with volume replacement followed by vasopressor therapy to increase the BP. However, if hypotension is the result of left ventricular failure, IV inotropes (e.g., dopamine, dobutamine) might be needed.

When would the nurse be sure to hold a beta blocker drug and notify the health care provider? A. When a client states he or she woke up with a headache. B. When a client's respiratory rate is 26 breaths/min on room air. C. When a client is scheduled for a chest x-ray. D. When a client's heart rate is less than 50 beats/min and SBP is less than 100 mm Hg.

D The nurse would not give beta blockers if the pulse rate was below 50 beats/min or the systolic BP was below 100 mm Hg. He or she would first check with the health care provider. The beta-blocker agent could lead to persistent bradycardia or further reduction of systolic BP, leading to poor peripheral and coronary perfusion.

What priority question would the nurse ask before administering SL nitroglycerin to a middle-aged male client with client pain? A. "Have you taken a medication for erectile dysfunction within the past 24 to 48 hours?" B. "Do you have a family history of heart disease, especially parents and grandparents?" C. "Have you experienced any other symptoms with your chest pain?" D. "What were you doing when the chest pain started?"

A Before administering NTG, ensure that the male client has not taken any phosphodiesterase inhibitors for erectile dysfunction such as sildenafil, tadalafil, avanafil, or vardenafil within the past 24 to 48 hours. Use of NTG at the same time as these inhibitors can cause profound hypotension. Remind clients not to take these medications within 24 to 48 hours of one another.

About which associated symptoms would the nurse ask a client with a history of intermittent episodes of chest pain? Select all that apply. A. Diarrhea B. Nausea C. Shortness of breath D. Joint pain E. Dizziness F. Diaphoresis

B, C, E, F Signs and symptoms associated with anginal chest pain include: nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath. Diarrhea and joint pain are not associated with anginal pain.

Which finding most strongly indicates left heart failure in a client when the nurse auscultates heart sounds? A. Murmur B. Split S1 and S2 C. S3 gallop D. Pericardial friction rub

C A client who develops left heart failure would have the presence of an S3 heart sound as well as crackles. Wheezing, tachypnea, and frothy sputum are noted when a client develops pulmonary edema.

Which diagnostic test is performed after a client's acute stage of an unstable angina episode to determine if there are cardiac changes that are consistent with ischemia? A. Electrocardiogram B. Echocardiography C. Exercise tolerance test D. Chest CT scan

C After the acute stages of an unstable angina episode, the cardiac health care provider often requests an exercise tolerance test (stress test) on a treadmill to assess for ECG changes consistent with ischemia, evaluate medical therapy, and identify those who might benefit from invasive therapy.

Which client does the nurse expect to have the highest risk for death related to damage to the left ventricle? A. Client with an inferior wall MI (IWMI) B. Client with lateral wall MI (LWMI) C. Client with a posterior wall MI (PWMI) D. Client with an arterior wall MI (AWMI)

D Clients with anterior wall MIs (AWMIs) have the highest mortality rate because they are most likely to have left ventricular failure and dysrhythmias from damage to the left ventricle.

Which early reaction is most common in clients with chest discomfort associated with unstable angina or myocardial infarction (MI)? A. Depression B. Anger C. Fear D. Denial

D Denial is a common early reaction to chest pain associated with angina or MI. On average, the client with an acute MI waits more than 2 hours before seeking medical attention. Often, he or she rationalizes that symptoms are caused by indigestion or overexertion. In some situations, denial is a normal part of adapting to a stressful event. However, in this case, denial interferes with identifying a symptom such as chest pain and can be harmful.