AH2 - Exam 1 - Lippincott 11ed - Test 1 - The Client with Acute Coronary Syndromes

29. The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective? 1. Decreased chest pain. 2. Increased blood pressure. 3. Decreased blood pressure. 4. Decreased heart rate.

1. Decreased chest pain. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related to the angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

4. A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.

1, 4, 5 1. Reduces myocardial oxygen consumption. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

2. A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L (3.5 mmol/L). 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.

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

5. A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? _________________ mL/h.

24ml/hr. First, calculate how many units are in each milliliter of the medication: 25,000 units/500 mL = 50 units/1 mL Next, calculate how many milliliters the client receives per hour: 1,200 units/1 hour / 50 units/1 mL = 1,200 units/1 hour x 1 mL/50units = 24 mL/hour.

17. The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following in which order from first to last? 1. Obtain a history of which drugs the client has used recently. 2. Administer the prescribed dose of morphine. 3. Position electrodes on the chest. 4. Take vital signs.

3, 4, 2, 1 3. Position electrodes on the chest. 4. Take vital signs. 2. Administer the prescribed dose of morphine. 1. Obtain a history of which drugs the client has used recently. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.

30. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modifcation may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the risk factor behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior.

3. Rewarding the client whenever the acceptable behavior is performed. A basic principle o behavior modica-tion is that behavior that is learned and continued is behavior that has been rewarded. Other reinorce-ment techniques have not been ound to be as eec-tive as reward.

20. Which of the following is an expected out-come for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: 1. Continues to have severe chest pain. 2. Can identify risk factors for MI. 3. Participates in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities with-out pain.

4. Can perform personal self-care activities with-out pain. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.

26. The nurse is caring for a client who recently experienced a myocardial ifarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.

1, 3, 4 1. The client should report unexpected bleeding or bleeding that lasts a long time. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side efffects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

10. A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admit-ting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Prescribe the chest radiograph.

1. Administer the morphine. Although obtaining the ECG, chest radio-graph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

3. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12-lead electrocardiogram.

1. Assess for changes in vital signs. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle con-tracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

33. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia.

1. Cardiac arrhythmias. Cardiac arrhythmias are commonly observed with administration o t-PA. Cardiac arrhythmias are associated with reperusion o the cardiac tissue. Hypotension is commonly observed with administration o t-PA. Seizures and hypother-mia are not generally associated with reperusion o the cardiac tissue.

9. A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.

1. Heart rate irregular with S3. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

32. After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds.

1. Observe the client for chest pain. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client or chest pain is the nursing assessment priority because closure o the previously obstructed coronary artery may recur. Clients who receive t-PA requently receive heparin to prevent closure o the artery ater administration o t-PA. Careul assess-ment or signs o bleeding and monitoring o partial thromboplastin time are essential to detect complica-tions. Administration o t-PA should not cause ever.

16. The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. Obtain an infusion pump for the medication. 2. Take the blood pressure every 4 hours. 3. Monitor urine output hourly. 4. Obtain serum potassium levels daily.

1. Obtain an infusion pump for the medication. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

6. An older adult has chest pain and shortness of breath. The health care provider prescribes nitro-glycerin tablets. What should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between the cheek and gums until it dissapears

1. Put the tablet under the tongue until it is absorbed. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.

7. The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. 3. SpO2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities. 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.

12. When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. Promote hydration. 2. Dissolve clots. 3. Prevent kidney failure. 4. Treat dysrhythmias.

2. Dissolve clots. Thrombolytic drugs are administered within the rst 6 hours ater onset o an MI to lyse clots and reduce the extent o myocardial damage.

34. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking.

2. History of cerebral hemorrhage. A history o cerebral hemorrhage is a con-traindication to administration o t-PA because the risk o hemorrhage may be urther increased. Age greater than 60 years, history o heart ailure, and cigarette smoking are not contraindications.

21. Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions.

2. Increased urine output. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.

14. A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing? 1. Call for urine output less than 30 mL/h for 2 consecutive hours. 2. Metoprolol (Lopressor) 5 mg IV push. 3. Prepare for a pulmonary artery catheter insertion. 4. Titrate dobutamine (Dobutrex) to keep systolic BP greater than 100.

2. Metoprolol (Lopressor) 5 mg IV push. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued.

19. While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and oxygen at 2 L/min. The nurse's first course of action should be to: 1. Increase the IV infusion rate. 2. Notify the physician promptly. 3. Increase the oxygen concentration. 4. Administer a prescribed analgesic.

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

25. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth.

2. Small, easily digested meals. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

35. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died ftom a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies.

2. Start an IV infusion. Advanced cardiac lie support recom-mends that at least one or two IV lines be inserted in one or both o the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood or the laboratory are important but secondary to starting the IV line.

28. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse? 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." 2. "The triglycerides are elevated and will not return to normal without these medications." 3. "The CRP is elevated indicating infammation seen in cardiovascular disease, which can be lowered by the medications prescribed." 4. "These medications will reduce the risk of type 2 diabetes."

3. "The CRP is elevated indicating infammation seen in CRP is a marker of infammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.

23. A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? 1. Cardiac output. 2. Right atrial blood flow. 3. Left end-diastolic pressure. 4. Cardiac index.

3. Left end-diastolic pressure. When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip o the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate refection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.

24. After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation.

3. Prevent thrombophlebitis and blood clot formation. Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.

27. Which client is at greatest risk for coronary artery disease? 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L). 3. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin. 4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).

4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L). The woman who is 65 years old, overweight, and has an elevated LDL is at great-est risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obe-sity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

36. Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4. Fluid-filled alveoli.

4. Fluid-filled alveoli. Crackles are auscultated over fuid-lled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

1. A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.

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

31. Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is adminis-tered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.

4. Revascularize the blocked coronary artery. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most eective when administered within the rst 6 hours ater onset o MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

8. The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: 1. Administer atropine 0.5 mg IV push. 2. Auscultate for abnormal heart sounds. 3. Prepare for transcutaneous pacing. 4. Take the client's blood pressure.

4. Take the client's blood pressure. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and deter-mine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.