Quiz 3 Ques

The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second-degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

b. Atrial fibrillation or flutter Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. New murmur c. S1 heart sound d. S3 heart sound

b. New murmur The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

c. Death of cardiac muscle from lack of oxygen (tissue necrosis). Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches. Coronary artery spasms and transient oxygen imbalance are not related to a myocardial infarction. Ischemia, if not reversed, will eventually lead to tissue necrosis.

Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave e. Frequent PVCs

c. Non-Q wave d. Q wave AMI can be classified as Q wave or non-Q wave.

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "I have an incredible headache!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

a. "I have an incredible headache!" The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. The worst complication is intracranial bleeding. Any neurological signs and symptoms must be taken seriously, and all fibrinolytic and/or heparin therapies must be discontinued until this is ruled out.

The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel." e. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word "several" is vague.

The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min b. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg c. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg d. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

a. Accompanied by shortness of breath b. Feelings of fear or anxiety d. No relief from taking nitroglycerin e. Pain occurs without known cause The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion

A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min

a. Administer thrombolytic therapy unless contraindicated Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Because interventional cardiology is unavailable, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells

a. Administration of morphine b. Administration of nitroglycerin (NTG) d. Oxygen therapy The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct. Transfusion is not required except in the setting of severe anemia, which may limit oxygen delivery to the heart. Dopamine infusion is usually used to treat hypotension but causes tachycardia which would be deleterious for the patient having an AMI because it increases the heart's workload and demand for oxygen.

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

a. Advanced age b. Diabetes c. Ethnic background e. Smoking Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) a. Allay the patient's anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the provider. d. Monitor the patient's cardiac rhythm throughout the procedure. e. Obtain informed consent by informing the patient of procedural risks.

a. Allay the patient's anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the provider. d. Monitor the patient's cardiac rhythm throughout the procedure. During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the provider to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the provider and should occur before the procedure begins.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

a. Allow family members to remain at the bedside. Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? a. Arterial lactate level of 1.0 mEq/L b. Cardiac output of 2.5 L/min c. Mixed venous (SvO2) of 40% d. Cardiac index of 1.5 L/min/m2

a. Arterial lactate level of 1.0 mEq/L An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits, indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

a. Assess for any hemodynamic effects of the rhythm. Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

a. Assess the IV site hourly. Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the clients integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a. Assist the client to the chair for meals and to the bathroom. c. Ensure the client wears TED hose or sequential compression devices. e. Take and record a full set of vital signs per hospital protocol. The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide c. Dobutamine infusion d. Dopamine hydrochloride infusion

a. Blood transfusion Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.

A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture e. Chest pain

a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI. Chest pain is a possible symptom of AMI.

The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 d. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm-5

a. Cardiac index (CI) of 1.2 L/min/m3 A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles), requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm-5; and the systemic vascular resistance of 1400 dynes/sec/cm-5

Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? a. Check the inflation volume of the flush system pressure bag. b. Disconnect the flush system from the arterial line catheter. c. Zero reference the transducer system at the phlebostatic axis. d. Reduce the number of stopcocks in the flush system tubing.

a. Check the inflation volume of the flush system pressure bag. To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is inappropriate and could increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss.

Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints e. Ensuring all junctions remain tightly connected

a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening e. Ensuring all junctions remain tightly connected Options A, B, C, and E are required to ensure proper functioning of the arterial line. There is no need to restrain all extremities. Depending on the patient's level of sedation, the right hand may need gentle restraint.

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

a. Compare measured pressures with other physiological parameters. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis. To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

a. Continue to educate the client on possible healthy changes. Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

a. Coronary artery bypass graft surgery Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%). The stent or PTCA are not appropriate because the patient is a candidate for CABG. The transmyocardial revascularization is reserved for patients who do not have other treatment options.

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site

a. Diminished breath sounds over left lung field Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

a. Do you have any concerns about sexuality? Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.) a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device e. Biventricular pacemaker

a. Dobutamine b. Intraaortic balloon pump c. Nesiritide This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.

Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.

a. Dysrhythmias are common occurrences. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain. Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

a. Emergent pacemaker insertion The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. c. Maintain the balloon in the inflated position for 8 hours following insertion. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. e. Inflate and deflate the balloon on an hourly schedule

a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. To obtain an accurate pulmonary artery occlusion pressure (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction. There is no reason to inflate and deflate the catheter's balloon unless measurements are being obtained.

A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition? a. It is an autosomal dominant inherited disorder of connective tissue. b. It is caused by a random genetic mutation and is not familial. c. There are no drugs that help control the cardiac symptoms of the disease. d. Contact sports are permitted if precautions against concussion are taken.

a. It is an autosomal dominant inherited disorder of connective tissue. Marfan syndrome is an autosomal dominant inherited disorder of connective tissue with a definite familial pattern. Beta blockers and ACE inhibitors are commonly used to treat the condition. Contact sports and weight lifting are generally prohibited.

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distension b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses e. Hepatomegaly

a. Jugular venous distension b. Peripheral edema e. Hepatomegaly Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure. Crackles are indicative of left ventricular failure. Weak peripheral pulse are not a manifestation of right ventricular failure. Crackles are indicative of left sided failure.

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? a. Review daily the necessity of the central venous catheter. b. Cleanse the insertion site daily with isopropyl alcohol. c. Change the pressurized tubing system and flush bag daily. d. Maintain a pressure of 300 mm Hg on the flush bag.

a. Review daily the necessity of the central venous catheter. Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Cleansing the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line but does not reduce the risk of infection.

The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

a. The patient is not a candidate for thrombolysis. To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours. Therefore, this patient is not a candidate for this therapy.

A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. c. asthma. d. peripheral vascular disease.

a. erectile dysfunction. A history of the patient's use of sildenafil citrate or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies. The other conditions would not be a contraindication for nitroglycerin.

The nurse is educating a patient's family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? a. "The catheter will provide multiple sites to give intravenous fluid." b. "The catheter will allow the provider to better manage fluid therapy." c. "The catheter tip comes to rest inside my brother's pulmonary artery." d. "The catheter will be in position until the heart has a chance to heal."

b. "The catheter will allow the provider to better manage fluid therapy." A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy.

The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? a. "It will be worth it to have a healthy spouse, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then let the children eat whatever they want."

b. "The low-cholesterol diet is one from which everyone can benefit." Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease. It will be easier if the family members all eat the same type of meal, so the nurse should suggest this option. Asking whether it's worth the trouble is not giving the spouse any information with which to make decisions. A diet low in cholesterol requires changing more than just a few things.

Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard, and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion. Stress and strain can increase the heart's oxygen demands but do not typically cause coronary artery disease. Coronary artery disease is a chronic illness. The patient asking for pills and a return to a previous lifestyle does not understand how risk factors lead to coronary artery disease.

A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best? a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

b. Allow continued bathroom privileges. This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

The provider writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's invasive line, what is the priority nursing action? a. Apply an air occlusion dressing to insertion site. b. Apply pressure to the insertion site for 5 minutes. c. Elevate the affected limb on pillows for 24 hours. d. Keep the patient's wrist in a neutral position.

b. Apply pressure to the insertion site for 5 minutes. Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not the standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place but unnecessary after catheter discontinuation.

Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place. e. Maintain NPO status for 12 hours.

b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity. NPO status does not need to be maintained after the patient is fully alert.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

b. Assess the client for bleeding. A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

b. Assist the client into a position of comfort in bed. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing. Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? a. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. c. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. d. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety.

Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? a. Zero referencing the transducer at the level of the phlebostatic axis following insertion b. Calibrating the system with a central venous blood sample and arterial blood gas value c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

b. Calibrating the system with a central venous blood sample and arterial blood gas value To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? a. Apply a pressure dressing to the insertion site. b. Ensure that all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.

b. Ensure that all tubing connections are tightened. Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; radiography is not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

b. Ensure the balloon does not remain wedged. If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

b. Expired food in the refrigerator Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics

b. Give the client an aspirin. The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

b. Hypertension c. Obesity d. Smoking e. Stress Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock e. Fever

b. Hypovolemia c. Myocardial infarction d. Shock Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise and fever.

While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? a. Diuretics b. Intravenous fluids c. Negative inotropic agents d. Vasopressors

b. Intravenous fluids Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. Administration of diuretics would worsen the patient's volume status. Negative inotropes would not improve the patient's volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state.

A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

b. Left ventricular assist device (LVAD) LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

b. Notify the provider immediately. If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? a. A dampened arterial line waveform b. Numbness and tingling in the left hand c. Slight bloody drainage at subclavian insertion site d. Slight redness at subclavian insertion site

b. Numbness and tingling in the left hand Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

b. The best source is fish, but pills have benefits too. Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

b. The heparin keeps that artery from getting blocked again. After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such.

The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? a. The mechanical ventilator is malfunctioning. b. The patient may require fluid resuscitation. c. The arterial line may need to be replaced. d. The left limb may have reduced perfusion.

b. The patient may require fluid resuscitation. The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure. A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion.

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

b. Transesophageal echocardiogram In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns. The other tests do not alter the gag reflex.

The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? a. Document a pulmonary artery catheter occlusion pressure. b. Zero reference the transducer system at the phlebostatic axis. c. Inflate the pulmonary artery catheter balloon with 1 mL air. d. Inject 10 mL of 0.9% normal saline into the proximal port.

b. Zero reference the transducer system at the phlebostatic axis. To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed before obtaining readings. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required before obtaining a cardiac output. The nurse injects 5-10 mL of normal saline into the proximal port in order to measure the cardiac output; this is not a step done before obtaining the measurement.

An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

b. compliance with diuretic therapy. Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure. Notifying the provider of a weight gain and assessing a pulse are important self-care activities but will not prevent a recurrence of heart failure. Nitroglycerin is used for coronary artery disease.

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

c. 1630 (4:30 PM) The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).

The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg and 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mm Hg and a normal oxygen saturation does not require immediate treatment.

The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? a. Activate the rapid response system. b. Place the patient in Trendelenburg position. c. Assess the cuff for proper arm size. d. Administer 0.9% normal saline bolus.

c. Assess the cuff for proper arm size. Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary.

After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? a. Apply 50% oxygen via Venturi mask. b. Insert an indwelling urinary catheter. c. Begin a dobutamine infusion. d. Obtain stat cardiac enzymes and troponin.

c. Begin a dobutamine infusion. The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time.

While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline.

c. Deflate the balloon and obtain a chest x-ray study to determine line placement. Balloon inflation should never be forced because the PAC may have migrated farther into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurse's scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

c. Dyspnea and crackles In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

c. Echocardiogram Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers. The ECG provides information related to the heart's electrical activity. A cardiac catheterization directly visualizes coronary arteries. Electrophysiology studies are done to evaluate dysrhythmias.

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

c. It increases the force of the hearts contractions. A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.

The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and aspiration of tube feeding, and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

c. Maintain airway patency. Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications.

A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

c. Myocardial remodeling Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta blockers d. Statins, bile acid, and nicotinic acid

c. Nitroglycerin, oxygen, and beta blockers Conservative intervention for the patient experiencing angina includes nitrates, beta blockers, and oxygen.

A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

c. Partial occlusion of a coronary artery with a thrombus In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy. Complete occlusion is associated with a myocardial infarction. A fatty streak is present in all vessels affected by coronary artery disease. Vasospasm leads to Prinzmetal's angina.

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

c. Put on a pair of gloves. For the nurses safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.

The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

c. Radiofrequency catheter ablation Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway. A cardioverter-defibrillator is used on patients with potentially lethal rhythms such as ventricular fibrillation. A pacemaker is not used for this condition.

A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

c. Silent myocardial infarction Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. These can occur with no presenting signs or symptoms; however, the patient's troponin levels and ECG are consistent with an MI. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients. The patient does not fit the criteria for hypokalemia, a non-Q wave MI, or unstable angina.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

c. Stop the infusion and call the provider. A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.

c. The distal tip of the catheter is in the appropriate position. X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery.

The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. dopamine. b. dobutamine. c. adenosine. d. atropine.

c. adenosine. If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed. Dopamine and atropine are not used.

The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

c. contact the physician immediately and begin prepping the patient for surgery. These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

A patient is having an emergent coronary intervention, and the nurse is starting an infusion of abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best? a. "This will help prevent chest pain until the intervention is complete." b. "This medication dries oral and respiratory secretions during the procedure." c. "This is a mild sedative and amnesic agent, so you'll be very relaxed." d. "This drug helps prevent blood clotting and is often used for this procedure."

d. "This drug helps prevent blood clotting and is often used for this procedure." Abciximab is a glycoprotein IIb/IIIc inhibitor and antiplatelet agent. It is used to prevent clotting in acute coronary syndromes and coronary intervention patients. The other statements are inaccurate.

The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's orders? a. Titrate supplemental oxygen to achieve a SpO2 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.

d. Administer furosemide (Lasix) 20 mg intravenously. A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen and obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.

The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? a. Limit the patient's supine position to no more than 10 seconds. b. Administer antianxiety medications while recording the pressure. c. Encourage the patient to take slow, deep breaths while supine. d. Elevate the head of the bed 45 degrees while recording pressures.

d. Elevate the head of the bed 45 degrees while recording pressures. Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient who becomes anxious and tachypneic when flat. Administering antianxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow, deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure.

The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.

d. Ensure alarm limits are turned on. When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in the patient's condition. Hemodynamic values and waveforms are recorded at scheduled intervals, and it is important that the tubing not be too long; however, alarm alerts are of highest priority. The lines are zero referenced per hospital policy, more frequently than daily.

During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? a. Deflate the balloon while slowly withdrawing the catheter. b. Instruct the patient to cough and deep-breathe forcefully. c. Inflate the catheter balloon with an additional 1 mL of air. d. Ensure lidocaine hydrochloride (IV) is immediately available.

d. Ensure lidocaine hydrochloride (IV) is immediately available. During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.

Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

d. Left main coronary artery Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention. Lesions in the other locations are candidates for this procedure.

The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

d. Perform hand hygiene. To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation. b. Place the patient in the supine position and document the average PAOP obtained after three measurements. c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation. Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

d. Prepare to administer a fluid bolus. Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.

A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

d. Statins The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs such as bile acid resins and nicotinic acid. Nitroglycerin is used for chest pain.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

d. Tell the client that anxiety is common and that you can help. Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the clients anxiety.

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? a. Increase supplemental oxygen and notify respiratory therapy. b. Notify the provider immediately of the assessment findings. c. Obtain a stat chest x-ray film to verify proper catheter placement. d. Zero reference and level the catheter at the phlebostatic axis.

d. Zero reference and level the catheter at the phlebostatic axis. A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant provider intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

c. Poor peripheral pulses and cool skin Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.