CAD/MI

5-25

CK Female: ____-____ mcg/mL

3 ( The dressing should be left in place for at least the first day after the client is discharged to prevent dislodging the clot. Heavy lifting and exercise should be avoided for several days. A small hematoma or bruise is expected and is not abnormal. It is not necessary to keep the affected extremity straight after the client is off bed rest. Focus: Prioritization)

11. Which instruction would you be sure to include in a discharge plan for Ms. S after her cardiac catheterization? 1. "Avoid heavy lifting and exercise today." 2. "Report any hematoma, even a small one, to the physician." 3. "Leave the dressing in place for the first day that you are at home." 4. "Keep your affected extremity straight while sleeping for several days."

1 (IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continous system and more frequently than q4 hrs. Hourly urine outputs are not always required. Obtaining serum K levels is not associated with nitroglycerin infusion)

The HCP 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 BP every 4 hrs 3. monitor urine output hourly 4. obtain serum K levels daily

2 (late onset puberty is NOT considered a risk factor. Risk factors for atherosclerosis include; family history of artherosclerosis, cigarette smoking, HTN, high cholesterol, male, diabetes, obesity and physical inactivity)

Which is not a risk factor for the development of atherosclerosis? 1 family history of early heart attack 2. late onset of puberty 3. total blood cholesterol level >220 4. elevated fasting blood glucose concentration

1 (further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP)

A 68 year old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first: 1. inquire about the onset, duration, severity and precipitating factors of the heaviness 2. administer O2 via nasal cannula 3. offer pain meds for the chest heaviness 4. inform the HCP of the chest heaviness

b (Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for the treatment of atrial arrhythmias; thus, Answer A is incorrect. Answers C and D are incorrect choices because lidocaine slows the heart rate, so it is not used for the treatment of heart block or bradycardia.)

Lidocaine is a medication frequently ordered for the client experiencing: a Atrial tachycardia b Ventricular tachycardia c Heart block d Ventricular bradycardia

3 (pasta, tomato sauce, salad, and coffee would be the best selection for the client follwing a low cholesterol diet.)

The client who experiences angina has been told to follow a low cholesterol diet, which meal would be best: 1. hamburger, salad and milk shake 2 baked liver, green beans and coffee 3. spaghetti with tomato sauce, salad and coffee 4. fried chicken, green beans and skim milk

3 (Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of MI. Focus: Prioritization)

20. You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min

3

As an initial step in treating a client with angina the HCP prescribes nitro tabs 0.3 mg. given SL. This drugs principal effects are produced by: 1. antispasmodic effects on the pericardium 2. causing an increased myocardial o2 demand 3. vasodilation of peripheral vasculature 4. improved conductivity in the myocardium

2 (A troponin T level of more than 0.20 ng/mL is an elevated level and indicates myocardial injury or infarction. Although the other laboratory values are all abnormal, none of them is life threatening. Focus: Prioritization)

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, "It just gets worse and worse." Ms. S has been under a physician's care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker, but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 4. All of these laboratory values were obtained in the ED. Which value has immediate implications for the care of this client? 1. Potassium level of 3.4 mEq/L 2. Troponin T level of more than 0.20 ng/mL 3. Glucose level of 123 mg/dL 4. Slight elevation of white blood cell count

1 (Morphine sulfate has been ordered to relieve the chest discomfort that is common in the setting of acute myocardial infarction. Relief from the chest pain is the highest priority at this time. Ranitidine is a histamine2 blocker used to prevent gastric ulcers. Scheduling an echocardiogram or drawing blood for coagulation studies, although important, will not help relieve chest discomfort. Focus: Prioritization)

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, "It just gets worse and worse." Ms. S has been under a physician's care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker, but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 5. Ms. S reports worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and you notify the health care provider. Which order takes priority at this time? 1. Administer morphine sulfate 2 mg IV push. 2. Schedule an echocardiogram. 3. Draw blood for coagulation studies. 4. Administer ranitidine (Zantac) 75 mg orally every 12 hours.

1,3,4 (Clopidogrel is generally well absorbed and may be taken with or without food. it should be taken at the same time each day, and while food may help prevent GI upset, food has no effect on absorption. Bleeding is the most common adverse effect. The client must understand the importance of reporting any unexpected prolonged, or excessive bleeding including blood in the urine or stool. Increased bruising or bleeding gums are possible side effects, and clients should be aware of the possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for MI, ischemic stroke, PAD or acute coronary syndrome. It is not necessary to drink a glass of water after taking clopidogrel.)

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

a (ECG changes associated with hypokalemia are peaked P waves, flat T waves, depressed ST segments, and prominent U waves. Answers B, C, and D are not associated with low potassium levels, so they are incorrect.)

A client admitted with gastroenteritis and a potassium level of 2.9mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results? a A depressed ST segment b An elevated T wave c An absent P wave d A flattened QRS

3 (clients taking nifedipine should inspect gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs)

A client with angina is taking nifedipine. What instructions should the nurse give? 1. monitor BP monthly 2. perform daily weights 3. inspect gums daily 4. limit intake of green leafy veges

b (Cardiac dysrhythmias are the most common complication for the client with a myocardial infarction. Answers A and C do not relate to myocardial infarction; therefore, they are incorrect. Answer D is incorrect because it is not the most common complication following a myocardial infarction.)

A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is: a Right ventricular hypertrophy b Cardiac dysrhythmia c Left ventricular hypertrophy d Hyperkalemia

2 (Chest pain can be an indicator of additional myocardial muscle damage. Additional episodes of chest pain significantly affect the client's plan of care. Small increases in heart rate and blood pressure after activity are to be expected. The client's temperature, only 0.2° higher than at admission, is not a priority at this time. Focus: Prioritization, delegation, supervision)

Ms. S's CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 8. Ms. S's condition is stable, and she has been transferred to the cardiac step-down unit. What should you instruct the UAP to report immediately? 1. Temperature of 99° F (37.2° C) with morning vital sign monitoring 2. Chest pain episode occurring during morning care 3. Systolic blood pressure increase of 8 mm Hg after morning care 4. Heart rate increase of 10 beats/min after ambulation

1,3,4

The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test? Select all that apply. 1 Creatine kinase 2 Ammonia 3 Myoglobin 4 Troponin T 5 Gamma-glutamyl transferase 6 Bilirubin

c (The LDH and CK MB are specific for diagnosing cardiac damage. Answers A, B, and D are not specific to cardiac function; therefore, they are incorrect.)

The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage? a SGOT and LDH b SGOT and CK BB c LDH and CK MB d LDH and CK BB

1 2 4 3 (When a client returns from having a transluminal balloon angioplasty with femoral access, the nurse should first obtain baseline VS and O2 to determine evidence of bleeding or decreased tissue perfusion. The nurse should next assess the pedal pulses to determine if the client has adequate peripheral tissue perfusion. Next the nurse should inspect the cath site and then determine color ad sensation in the affected leg)

The nurse is caring for a client who has just returned from having a percutaneous transluminal balloon angioplasty with femoral artery access. In which order from first to last should the nurse obtain information about the client? 1 vital signs and O2 saturation 2. pedal pulses 3. color and sensation of extremity 4. catheterization site

d (Rationale: Nitroglycerin is ordered to be taken every 5 minutes 3 times for pain. Waiting 10 minutes between doses is not appropriate if the client is in pain. Ten liters of oxygen is an unsafe dose. The nurse instructs the client to call 911 if the pain does not subside after 3 doses. )

The nurse is planning discharge instructions for a client diagnosed with coronary artery disease (CAD). The client, who is to take nitroglycerin at home for substernal chest pain, asks the nurse what to do if there is still pain after taking the medication. What is the appropriate response made by the nurse? a "Wait for 10 minutes before taking a second pill." b "Apply oxygen at 10 liters per minute." c "Take an aspirin and call 911." d "Take another nitroglycerin tablet."

a (EKG strip indicates atrial fibrillation. The irregular rhythm predisposes the patient to develop blood clots. Anticoagulants, such as aspirin, are given to prevent an ischemic stroke due to clot formation. The other NSAIDS listed are not commonly given to prevent clot formation.)

The nurse notes the following ECG monitor strip. The nurse would anticipate an order for which medication? a Aspirin (ASA) b Acetaminophen (Tylenol) c Ibuprofen (Motrin) d Indomethacin (Indocin)

4 (The nurse should first assess the clients tolerance to the drop in HR by checking the BP and LOC and determine if atropine is needed. If the client is symptomatic, atropine and transutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.)

The nurse notices that a clients HR decreases from 63 to 50 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 clients BP

2 (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 clients 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 NPO unless their condition is very unstable)

Which is the most appropriate diet for a client during the acute phase of MI? 1. liquids as desired 2. small, easy digested meals 3. three regular meals per day 4. NPO

b,c,d (B: The SA node consists of a cluster of cells that are situated in the upper part of the wall of the right atrium (the right upper chamber of the heart). C: When action potentials reach the AV node, they spread slowly through it. D: Action potentials pass slowly through the atrioventricular node. A: The SA node is the heart's natural pacemaker.)

Which of these statements regarding the conduction system of the heart is NOT correct? Select all that apply. A The sinoatrial (SA) node of the heart acts as the pacemaker. B The SA node is located on the upper wall of the left atrium. C The AV node conducts action potentials rapidly through it. D Action potentials are carried slowly through the atrioventricular bundle.

2 (thrombolytic drugs are administered within the first 6 hours after onset of MI to lyse clots and reduce the extent of myocardial damage)

While administering a thrombolytic drug to the client who is experiencing a myocardial infarction 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 (Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization)

1 You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

1 (headache is common with nitro that can be alleviated with aspirin, acetaminophen or ibuprofen. Lying flat will increase blood flow to the head and may increase pain.)

A client has a throbbing headache when nitro is taken for angina. The nurse should instruct the client that 1. tylenol or motrin can be taken for this common side effect 2. nitro should be avoided if the client is experiencing this serious side effect 3. taking the nitro with a few glasses of water will reduce the problem 4. the client should lie in a supine position to alleviate the headache

a (The​ troponin, CPK, and​ Ck-MB are collectively known as cardiac enzymes and must be monitored closely to evaluate for cardiac damage. The other labs listed are important to monitor the​ client's status, but the cardiac enzymes together are more important to monitor for cardiac damage.)

Benny​ Spencer, a​ 57-year-old man, arrives in the emergency department reporting persistent chest pain for the last 48 hours. The chest pain is rated as a 7 on a​ 1-10 scale, and it radiates up the​ client's neck. What lab values will be the most important for the nurse to​ monitor? ​a Troponin, CPK, and​ Ck-MB ​b BMP, CPK, and troponin ​c PTT, CBC, and​ Ck-MB d CBC and CPK

5-35

CK Male: _____-_____mcg/mL

3 (nitro may be used prophalactically before stressful physical activities such as stair climbing to remain pain free. Climbing the stairs early would have no impact on pain, resting before or after is unlikely to prevent activity related pain)

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which instruction would most likely help the client prevent this problem? 1. climb the stairs early in the day 2. rest for at least 1 hr before climbing the stairs 3. take nitro tab before climbing the stairs 4. lie down after climbing the stairs

c (Conservative treatment would include regular physical exercise such as walking at a brisk pace. Fat should be no more than​ 10% of the daily diet. Smoking should be totally​ eliminated, usually through a cessation program or the use of assistive drugs such as nicotine patches. By controlling​ cholesterol, the client can help control CAD. The statins are one group of medications used to decrease circulating cholesterol.)

Ms. Fortune has been diagnosed with narrowing of the coronary arteries. What would be the​ appropriate, conservative initial treatment for this​ condition? a Take statins as prescribed b Cut smoking by half the amount c Exercise 3 times a week for 30 minutes d Eat a diet with a minimum of​ 20% fat

3 (The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority. Focus: Prioritization)

10. You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

1, 4, 6 ( Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation)

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

2 (An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have ACS and with collaborative treatments such as coronary angioplasty and coronary artery stenting. Focus: Assignment)

7. You are the charge nurse for the coronary care step-down unit. Which client is best to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

1 (although obtaining the ECG, chest radiograph, and blood work are all important, the nurses priority action should be to relieve the crushing chest pain. Therefore administering the morphine sulfate is the priority action)

A 60-year-old comes into the ER with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include O2 by nasal cannula at 4 L/min, CBC, chest radiograph, a 12 lead 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

3

A client who has risk factors for coronary artery disease, including smoking cigarettes, eating a diet high in saturated fat, and leading a sedentary lifestyle. The nurse can coach this client to improve health by: 1. explaining how the risk factors lead to poor health 2. withholding praise until the client changes the risky behavior 3. helping the client establish a wellness vision to reduce health risks 4. instilling mild fear into the client about the potential outcomes of the risky health behaviors

2 (advanced cardiac life support recoomends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the HCP, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.)

A middle aged client being admitted to the hospital has a history of hypertension and informs the nurse that his father died from a heart attack at age 60. The client reports having indigestion. The nurse connects the client to a cardiac monitor which reveals eight premature ventricular contractions (PVC's) per minute. The nurse should: 1. call the HCP 2. start an IV line 3. obtain a portable chest radiograph 4 draw blood for laboratory studies

a ( Feedback Rationale: Re-establishing blood flow and cardiac tissue perfusion during an acute episode of CAD is imperative to minimize damage to the myocardium. Anxiety and Ineffective Health Maintenance are appropriate nursing diagnoses but do not take precedence over cardiac tissue perfusion. Decreased Cardiac Output results in decreased peripheral tissue perfusion and is a high priority but not as high as establishing perfusion to the heart. )

A nurse caring for a client with acute coronary artery disease (CAD) identifies which priority nursing diagnosis? a Ineffective Tissue Perfusion b Ineffective Health Maintenance c Anxiety d Decreased Cardiac Output

3 (encouraging the client to move the legs while in bed is a preventative 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. Theses exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation)

After an MI, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this excercise? 1. prepare the client for ambulation 2. promote urinary and intestinal elimination 3. prevent thrombophlebitis and clot formation 4. decrease the likelihood of pressure ulcer formation

d (Rationale: The catheter used to place the stent is usually inserted in the femoral artery. The affected leg is maintained in extension to prevent bleeding and hematoma formation. Chest tubes are not needed for this surgery and would not be secured to bed linens in any case. IV lines would be maintained as a saline lock in the event a line is needed for IV medications. Because the stent re-establishes blood flow to the myocardium, narcotic analgesics are rarely needed. )

An African American male client with a history of diabetes and stroke returns from coronary angioplasty with stent placement. Which priority action will the nurse perform at this time? a Treating chest pain with intravenous morphine as needed b Discontinuing intravenous lines when taking oral fluids c Securing chest tubes to the bedding d Maintaining leg extension on the affected side

3 (Cardiac monitoring is the highest priority, because the client's heart rate is rapid and irregular and the client is experiencing chest pressure. The client is at risk for life-threatening dysrhythmias such as frequent premature ventricular contractions (PVCs). Measuring vital signs every 2 hours, checking levels of cardiac markers, and recording a 12-lead ECG every 6 hours are important, but cardiac monitoring takes precedence. Focus: Prioritization)

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, "It just gets worse and worse." Ms. S has been under a physician's care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker, but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 2. Which physician order takes first priority at this time? 1. Measure vital signs every 2 hours. 2. Obtain a 12-lead ECG every 6 hours. 3. Place the client on a cardiac monitor. 4. Check levels of cardiac markers every 6 hours.

c (The most important focus for a patient with coronary artery disease is on lifestyle changes. The most appropriate are​ diet, exercise, and how to use prescribed medications. Safety concerns need to be assessed for the home environment prior to her return home. When to return to normal activity will be part of the discharge instructions written by the healthcare provider.)

Ms.​ Wolfe, who has coronary artery​ disease, is leaving the hospital to go home. Which aspect of home care is most important for her to focus​ on? ​a Follow-up care b Safety concerns c Lifestyle changes d Return to normal activity

2 ( a history of cerebral hemorrhage is a contraindication to adminstration of t-PA because the risk of hemorrhage may be further increased. Age >60, history of HF and cigarette smoking are not contraindications.)

Prior to the admin t-PA, the nurse should assess the client for which contradiction to administering the drug? 1. age >60 2. history of cerebral hemorrhage 3. history of HF 4. cigarette smoking

1 (nitro acts to decrease myocardial O2 consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased O2 needs. Decreased O2 demand reduces pain caused by heart muscle not receiving sufficient O2. While BP may decrease ever so slightly due to the vasodilation effects of nitro, it is only secondary and not related to the angina the client is experiencing. Increased BP would mean the heart would work harder, increasing O2 demand and thus angina. Decreased HR is not an effect of nitro)

The client has been managing angina episodes with nitroglycerin Which finding indicates that the therapeutic effect of the drug has been achieved? 1. decreased chest pains 2. increased BP 3. decreased BP 4. decreased HR

d (Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.)

The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: a Peaked P wave b Elevated ST segment c Inverted T wave d Prolonged QT interval

2 ( 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 BP and HR are stable)

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, bilateral basilar crackles. 2. confusion, urine output 15 mL over the last 2 hrs, orthopnea 3. SpO2 92 on nasal cannula, RR 20, 1+ edema of lower extremities 4. weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with excercise

b (The systemic analysis of the electrocardiogram shows the information in the question as criteria for sinus tachycardia. Answer A would reveal an irregular rhythm and an early or different P wave. Answer C is incorrect because the P waves would be saw-toothed and the P: QRS ratio would be 2:1, 3:1, or 4:1. Answer D requires an unidentifiable P wave and a PR interval of less than 0.12 seconds, so it is incorrect.)

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm? a Premature atrial complex b Sinus tachycardia c Atrial flutter d Supraventricular tachycardia

a (Rationale Phase 1 has the client moving from bed rest to providing​ self-care. An example of this is performing his own bathing. Phase2 of cardiac rehabilitation is characterized by increased​ activity, improvement of psychosocial​ status, and treatment of anxiety. In phase 3 the client is progressing independently in an exercise routine at home.)

The nurse is explaining the phases of cardiac rehabilitation to a client being prepared for discharge. What is a goal of phase 1 for the​ client? a Performs own bathing routine b Decreases anxiety c Improves psychosocial status d Increases exercise at home

a,b,e (Rationale When the healthcare provider believes that a client has experienced a heart​ attack, or myocardial infarction​ (MI), diagnostic tests will include cardiac markers including CPK and​ CK-MB and an ECG. A CBC and WBC will not be useful to confirm the diagnosis of an MI.)

The nurse is providing care to a client admitted to the coronary care unit for a suspected heart attack. Which diagnostic tests does the nurse anticipate to confirm the​ diagnosis? ​(Select all that​ apply.) a CPK b ECG c CBC d WBC ​e CK-MB

4 (combo of post menopausal, obesity and high LDL )

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

a (The client needs more instruction because returning to work is usually allowed within 72​ hours; 24 hours is too soon. All of the other statements are important teaching points that the client must be informed of prior to an angiogram being​ performed, and the client must demonstrate proper understanding.)

You are providing postprocedure instructions to the client who requires an emergent angiogram. What client statement indicates the need for further​ instruction? ​a "I will be able to return to full duty at work within 24​ hours." ​b "I will need to let you know if there is moisture under me after the​ procedure." ​c "I will need to use the call light when I need toileting​ assistance." ​d "I will need to lie still for up to 8 hours after the​ procedure."

4 ( Normal sinus rhythm with a rate of 88 beats/min is a normal finding. There is no need to delay the client's discharge, give early medications, or draw additional cardiac markers. Focus: Prioritization)

12. Before discharging Ms. S, the health care provider orders an ECG. This test reveals normal sinus rhythm with a heart rate of 88 beats/min. What is your best action at this time? 1. Delay the client's discharge until she is seen by the health care provider. 2. Administer the client's next dose of atenolol 3 hours early before she goes home. 3. Contact the health care provider and ask about drawing an additional set of cardiac markers. 4. Document this finding as the only action.

4 (The goal in pain management for the client with an acute MI is to completely eliminate the pain. Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time. Focus: Prioritization)

12. You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

1 (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 stnotic valve.)

A client 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. HR irregular with S3 2. HR irregular with S4 3. HR irregular with aortic regurgitation 4. HR irregular with mitral stenosis

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

An older adult has chest pain and SOB. The HCP prescribes nitroglycerin 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 its dissolved 4. Place the tablet between the cheek and gums until it disappears

d (The SA node is the natural pacemaker of the heart. The electrical stimulus from the SA node eventually reaches the AV node and is delayed briefly so that the contracting atria have enough time to pump all the blood into the ventricles. Once the atria are empty of blood the valves between the atria and ventricles close. At this point, the atria begin to refill and the electrical stimulus passes through the AV node and Bundle of His into the Bundle branches and Purkinje fibers.)

Arrange these parts of the conduction system of the heart in the correct order as an action potential would pass through them. 1. AV node 2. Purkinje fibers 3. Atrioventricular bundle 4. R and L bundle of His 5. SA node A SA Node - Purkinje Fibers - R and L bundle of His - Atrioventricular bundle - AV Node B SA Node - AV Node - Purkinje fibers - R and L bundle of His - Atrioventricular bundle C SA Node - Purkinje Fibers - Atrioventricular Bundle - R and L bundle of His - AV Node D SA Node - AV Node - Atrioventricular bundle - R and L bundle of His - Purkinje Fibers

1 (With frequent PVCs, the client is at risk for life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Amiodarone is an antidysrhythmic drug used to control ventricular dysrhythmias. Nitroglycerin and morphine can be given for chest pain relief. Atenolol is a beta-blocker, which can be used to control heart rate and decrease blood pressure. Focus: Prioritization)

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, "It just gets worse and worse." Ms. S has been under a physician's care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker, but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 3. The client's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs). Which drug should you prepare to administer first? 1. Amiodarone (Cordarone) IV push 2. Nitroglycerin (Nitrostat) sublingually 3. Morphine sulfate IV push 4. Atenolol (Tenormin) IV push

a (Rationale Prinzmetal​ (variant) angina occurs unpredictably and often at night. The client is currently experiencing either Prinzmetal or unstable angina and is at severe risk of a myocardial infarction. Stable angina is a predictable form of​ angina, which usually occurs when the work of the heart is increased by physical​ exertion, exposure to​ cold, or stress. This​ client's angina is unpredictable and occurs at rest. Coronary artery disease is the cause of​ angina, not the disorder which develops as a result of it.)

The client with a history of atherosclerosis has chest pain that is unrelated to​ activity, unpredictable, and often occurs while at rest. The client reports the pain has been becoming more frequent and​ severe, rating the current pain as 9 on a scale of 1 to 10. You recognize that the client is at severe risk of which​ disorder? a Myocardial infarction b Stable angina c Coronary artery disease d Prinzmetal angina

b (Rationale: Stable angina is predictable and is associated with increased activity, and is relieved by rest and nitrates. ECG changes, nocturnal pain, and weak peripheral pulses are not findings associated with stable angina)

The nurse in the clinic assesses a client with stable angina. What expectations does the nurse have for this client? a Persistent ECG changes b Correlation between activity level and pain c Increasing nocturnal pain d Weak peripheral pulses

1 (The nurse should first don gloves and apply direct pressure over the site to stop blood loss from the femoral artery. While the nurse will later observe the site for further bleeding and record the extent of bleeding, this is not the first action that is needed. If the bleeding cannot be controlled, the HCP who performed the procedure should be contacted, but first, an attempt to manually stop the bleeding with direct pressure is warranted. Protamin sulfate is the antidote for heparin sodium, but this is not an initial action to control the bleeding)

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is reciving IV heparin sodium at 1000 units per hr. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first: 1. don gloves and apply direct pressure over the site 2. observe and document the finding 3. notify the HCP 4. prepare the protamine sulfate for IV administration

a,c,d,e (Rationale A coronary​ angiogram, obtained through a procedure known as cardiac​ catheterization, is a radiographic study of the circulation of the coronary arteries. The client will be on bed rest for up to 8 hours after the​ procedure, with pressure applied to the insertion site. Food and drink are allowed as tolerated.)

The nurse is planning the education for a client being prepared for a coronary angiogram. What is appropriate information for the nurse to​ include? (Select all that​ apply.) a Pressure is applied to the insertion site b Allows ambulation within an hour of the procedure c Requires the insertion of a catheter d Can eat after the procedure e Will require the use of radiography

a,c,d,e (Rationale Coronary artery disease affects 13.2 to 16.8 million people in the United States and causes more than​ 607,000 deaths annually. A lack of oxygenated blood to the coronary arteries will decrease a​ client's ability to function and increase their risk of death.​ High-density lipoproteins attract​ cholesterol, returning it from peripheral tissues to the liver. Endothelial damage causes the body to send platelets to seal the area and leukocytes to fight inflammation. These protective mechanisms also contribute to the formation of fibrous plaque. Fibrous plaque protrudes into the arterial lumen and invades the muscular media layer of the vessel as well as the inner wall of the intima. This results in a decreased ability of the vessel to dilate.)

The nurse is teaching a client about coronary artery disease. Which responses by the client reflect an understanding of coronary artery​ disease? (Select all that​ apply.) ​a "Plaque impairs the ability of a vessel to dilate in response to increased oxygen​ demands." ​b "It decreases quality of life but does not increase a​ client's risk of​ death." ​c "Damage to the linings of my arteries can cause clots and​ blockage." d ​"It affects more than 13 million people in the United​ States." e ​"The increased levels of​ high-density lipoproteins​ (HDLs) decrease the risk of​ atherosclerosis."

a,b,e (Rationale: The client undergoing angiography has a large-bore catheter inserted through the femoral artery, so the priority of care is to monitor and prevent bleeding. The client will lie flat for several hours and the groin will be checked regularly. A sandbag may be placed to maintain constant pressure on the arterial puncture site. Elevating the foot of the bed would increase pressure and blood flow to the groin and increase the risk of bleeding, as would applying heat to the leg. )

The nurse receives an 82-year-old client with a history of A-fib from the angiography department. What priority actions will the nurse do next? (Select all that apply.) a Place the client supine for several hours. b Check the groin for bleeding or hematoma. c Elevate the foot of the bed or place pillows under the legs. d Apply heat to the calf of the leg. e Place a sandbag on the femoral site.

1 (cardiac arrhythmia are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.)

When monitoring the client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in: 1. cardiac arrhythmias 2. hypertension 3. seizure 4. hypothermia

4 (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 hospitilization 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.)

Which is an expected outcome for a client on the 2nd day of hospitalization after a myocardial infarction? 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 without pain

2 (furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase BP, decrease pain, or decrease arrhythmias)

Which is an expected outcome when a client is receiving an IV administration of furosemide? 1. increase BP 2. increased urine output 3. decreased pain 4. decreased premature ventricular contractions

1 ( the client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sex would not be unexpected and the client may be instructed to tak nitro to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected, the client may be instructed to take nitro to prevent this pain or may be restricted from doing such activities.)

Which symptom should the nurse teach the client with unstable angina to report immediately to the HCP? 1. a change in the pattern of the chest pain 2. pain during sex 3. pain during an argument 4 pain during or after physical activity

2 (PVC's are often the precursor to life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVC's occur at a rate greater than 5 or 6 per min in the post-MI client, the HCP should be notified immediateley. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocain hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the O2 concentration should not be the nurses first course of action: rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.)

While caring for a client who has sustained a 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 at 125 mL/hr and O2 @ 2L/min. The nurse should first: 1. increase the IV infusion to 150 mL/hr 2. notify the HCP 3. increase the O2 to 4L/min 4. administer the prescribed analgesic

b (The dye used for angiograms normally has iodine in​ it, which is also found in​ shellfish, and a shellfish allergy must be reported promptly. The emergent need for the angiogram supersedes the client eating within the last 30 minutes. Monitor for emesis and nausea. When the client expresses concerns over the​ procedure, the nurse should allow the client to express those concerns and answer any questions that the client may have within the​ nurse's scope of practice before notifying the primary healthcare provider. The angiogram done 7 years ago is not relevant to the emergent need for the angiogram.)

You are completing preprocedure teaching on a client scheduled for an emergent angiogram. Which assessment finding is most important to report to the primary care​ provider? a Client has eaten within the last 30 minutes. b Client is allergic to shellfish. c Client is expressing concern over the impending procedure. d Client had an angiogram 7 years ago.

4 (Nursing management for a client with 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 base on client comfort and maintaining a calm environment.)

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12 lead ECG reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first? 1. monitor daily weights and urine output 2. limit visitation by family and friends 3. provide client education on medications and diet 4. reduce pain and myocardial O2 demand

2 (the best monitor that the clients circulation remains intact, the dorsal surface of the right foot should be palpated. When the left side of the heart is catheterized, the cannula enters via an artery. In this instance, the right femoral artery was accessed. While all options assess arterial points of the right leg, the dorsal surface of the right foot (the pedal pulse) is the most distal. If this pulse point is present and unchanged from before the procedure, the other pulse points should also be intact)

A client returns from a L heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? 1. anterior to the right tibia 2. dorsal surface of the right foot 3. posterior to the right knee 4. right midinguinal area

1,4,5 (Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial O2 consumption, BP, and HR. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the HR. 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)

A client with acute chest pain is receiving IV morphine sulfate. Which is an expected effect of morphine? Select all that apply: 1. reduces myocardial O2 consumption 2. promotes reduction in RR 3. prevents ventricular remodeling 4. reduces BP and HR 5. reduces anxiety and fear

2 (nitroglycerin is a vasodilator that will lower BP. The client is having chest pain, and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The K and HR are wnl)

A client with chest pain is prescribed IV nitroglycerin. Which assessment is of GREATEST concern for the nurse initiating the nitroglycerin drip? 1. serum K is 3.5 2. BP is 88/46 3. ST elevation is present on the ECG 4. HR is 61

2 (cardiac cath is done in clients with angina primarily to assess the extent and the severity of the coronary artery block. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the cath results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac cath can be used to assess the fundtional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.)

A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains the client that this procedure is being used to: 1 open and dilate blocked coronary arteries 2. assess the extent of arterial blockage 3 bypass obstructed vessels 4 assess the functional adequacy of the valves and heart muscle

d (Rationale The client with acute coronary syndrome would exhibit substernal chest pain that occurs at rest and radiates to the left arm. The client experiencing a myocardial infarction would experience a sudden onset of burning chest pain.)

The nurse is caring for a client with a history of angina. Which assessment findings would support the diagnosis of a myocardial infarction​ (MI)? a Substernal chest pain b Pain at rest c Pain radiating to the left arm d Sudden onset of burning chest pain

2 (Since proton pump inhibitors such as omeprazole affect the metabolism of clopidogrel and decrease its effectiveness, the health care provider may want to discontinue the omeprazole in this client with unstable angina. The other medications should also be verified, but current national guidelines for clients with unstable angina indicate that providers should consider avoiding proton pump inhibitors in those who require clopidogrel. Focus: Prioritization)

15. The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel (Plavix). Which medication is most important to clarify further with the health care provider? 1. Aspirin (Ecotrin) 162 mg daily 2. Omeprazole (Prilosec) 20 mg daily 3. Metoprolol (Lopressor) 50 mg daily 4. Nitroglycerin patch (Nitrodur) 0.4 mg/hr

1 (Because TEE is performed after the throat is numbed using a topical anesthetic and possibly after IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the TEE but do not need to be implemented immediately. Focus: Prioritization)

16. At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

4 (Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization)

2 You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)

1 (Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available. Focus: Prioritization)

21. Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate.

2 4 3 1 (The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization)

26. You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

4 (The elevated troponin level should be reported to the HCP prior to the stress test as this change indicates myocardial damage. Sending the client to walk on a treadmill for stress testing would be contraindicated with evidence of recent myocardial injury and could further extend the damage. The other blood levels are helpful but not critical to this clients welfare at this point in time)

A client is admitted with chest pain and kept overnight for stress testing the next morning. Prior to sending the client to the stress test, the nurse reviews the results of the laboratory reports (see lab report). The nurse should report which elevated laboratory value to the HCP, prior to the stress test? 1. cholesterol level 2. ESR 3. PTT 4. troponin

4 (Measuring and recording vital sign values are within the scope of practice of the UAP. When the UAP makes a mistake, it is best to communicate specifically, stressing the importance of recording vital sign values after they have been obtained. Supervision should be done in a supportive rather than confrontational manner. Notifying the nurse manager is not appropriate at this time. Reprimanding the UAP in front of others also is not appropriate. Focus: Delegation, supervision)

7. You assign the UAP the task of taking the client's vital signs every 2 hours and recording the vital sign values in the electronic chart. Later you check the client's chart and discover that vital sign measurements have not been recorded. What is your best action? 1. Take the vital signs because the UAP is not competent to complete this task. 2. Notify the nurse manager immediately. 3. Reprimand the UAP at the nurses' station. 4. Speak to the UAP privately to determine why the values were not recorded.

1, 3, 4, 5, 6 ( All of these interventions are within the scope of practice of an experienced LPN/LVN. You would be sure to instruct the LPN/LVN when to notify you or the health care provider of any abnormal findings. Preparing a teaching plan requires additional education and is more suited to the RN. Taking vital signs and reminding the client about bed rest could also be delegated to the UAP. Focus: Delegation, supervision)

10. Ms. S is returning from a cardiac catheterization procedure. Which follow-up care orders could you delegate to an experienced LPN/LVN? (Select all that apply.) 1. Reminding the client to remain on bed rest with the insertion site extremity straight 2. Preparing a teaching plan that includes activity restrictions and risk factor modification 3. Measuring the client's vital signs every 15 minutes for the first hour 4. Assessing the catheter insertion site for bleeding or hematoma formation 5. Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs 6. Administer 2 tablets of acetaminophen (Tylenol) for back pain

2 (For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give you more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle. Focus: Prioritization)

13. You are preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had an MI and her husband. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

1, 2 (The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization)

6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

4 (Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. Focus: Prioritization)

8. At 9:00 pm, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine (Pepcid) for esophageal reflux. 3. The client has ST-segment elevations on the 12-lead ECG. 4. The client has had continuous chest pain since 8:00 am.

1 (HCTZ is a thiazide diuretic used to correct edema and lower blood pressure, and should be taken in the morning so that its diuretic effects do not keep the client up during the night. A side effect of HCTZ is loss of potassium, and clients may require potassium supplementation. Captopril is an angiotensin-converting enzyme inhibitor and will lower blood pressure. It is never appropriate to take twice the dose of this drug. Focus: Prioritization)

9. The health care provider orders captopril (Capoten) 12.5 mg by mouth (PO) twice daily and hydrochlorothiazide (HCTZ [Microzide]) 25 mg PO daily. Which information would you be sure to include when teaching the client about these drugs? 1. "Take your HCTZ in the morning." 2. "If you miss a dose of captopril, take two tablets next time." 3. "Avoid foods that are rich in potassium, such as bananas and oranges." 4. "You should expect an increase in blood pressure with these drugs."

2 (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. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock)

A client admitted for a myocardial infarction develops cardiogenic shock. An arterial line is inserted. Which prescription from the HCP should the nurse verify before implementing? 1. call for urine output <30 mL for 2 consecutive hrs 2. Administer metoprolol 5 mg IV push 3. Prepare for a pulmonary artery catheter insertion 4. Titrate dobutamine to keep systolic BP >100 mmHG

3 ( when wedged the catheter is "pointing" indirectly at the left end diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowly 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 teh clients cardiac output by the clients body surface area and is considered a more accurate reflection of the individual clients cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.)

A client has a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse should wedge the catheter to gain information about: 1. cardiac output 2. right arterial blood flow 3. left end diastolic pressure 4. cardiac index

2 (All of the 1200 hour assessments are signs of decreased cardiac output and can be an ominous sign in the client who has recently experienced an MI: the nurse should notify the HCP of these changes. Cardiac output and BP may continue to fall to dangerous levels, which can induce further coronary ischemia and extension of the infarct. While the client is currently hypotensive, giving fluid challenge/bolus can precipitate increased workload on a damaged heart and extend the MI. Exercise or walking for this client will increase both the HR and stroke volume, both of which will increase cardiac output, but the increased cardiac output will increase O2 needs especially in the heart muscle and can induce further coronary ischemia and extension of the infarct. The client is hypotensive. Although the client has decreased urinary output, this is the body's response to a decreasing cardiac output, and it is not appropriate to administer furosemide.)

An older adult had a myocardial infarction 4 days ago. At 0930, the clients BP is 102/64. After reviewing the clients progress notes (below), the nurse should first: Time: 0030 Urine output last 4 hrs: 90 mL Capillary refill: >3 seconds Blood pressure: 128/82 Extremities: Cool 1. give a fluid challenge/bolus 2. notify the HCP 3. assist the client to walk 4. administer the furosemide as prescribed

a,b,e (Rationale The causes of atherosclerosis are not known but research has shown a connection with modifiable risk factors such as​ cholesterol, triglycerides, lack of​ exercise, smoking,​ obesity, blood​ pressure, diet,​ stress, and diabetes. Elevated cholesterol is only one of the factors that can contribute to the development of plaque in the arteries. Excessive pressures within the arterial system can cause injury to the arterial endothelium. Endothelial damage promotes platelet adhesion and​ aggregation, and attracts leukocytes to the area. Risk factors such as​ age, gender, and heredity cannot be modified. The exact cause is​ unclear, but it is believed that​ fruits, vegetables, whole​ grains, and unsaturated fatty acids have nutrients that help protect the arteries from injury.)

A​ 58-year-old client who has a strong family history of coronary artery disease asks the​ nurse, "How can I decrease my chances of developing problems with my​ arteries?" Which response by the nurse is​ appropriate? ​(Select all that​ apply.) ​a "Keeping your blood pressure within normal levels will decrease the risk of injury to your​ arteries." ​b "Diets high in​ fruits, vegetables and unsaturated fatty acids appear to have a protective effect on the​ arteries." ​c "With your age and family​ history, there is little you can do besides take medication to prevent coronary artery​ disease." ​d "As long as your cholesterol is​ normal, your arteries will remain​ clear." ​e "You can reduce your risk by making some changes in your lifestyle such as moderate​ exercise."

3 4 2 1 (The nurse should first connect the client to the monitor by attaching the electrodes. ECG can be used to identify myocardial ischemia and infarction, rhythm, and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the clients heart. The nurse next obtains VS to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction pain; it may cause a transient decrease in BP. When the client is stable, the nurse can obtain a history of the clients drug use)

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. What should the nurse do in order of priority from first to last? 1. obtain a history of which drugs the client has recently used 2. administer the prescribed dose of morphine 3. position electrodes on the chest 4. take VS

a,b,c,e (Rationale Clinical manifestations of an MI include​ tachypnea, anxiety, vomiting and ECG changes in the Q wave. A client experiencing an MI would experience ST segment​ elevation, not depression.)

The nurse is caring for a client admitted with a possible myocardial infarction​ (MI). Which assessment findings are consistent with this​ diagnosis? ​(Select all that​ apply.) a Q wave changes b Tachypnea c Anxiety d ST segment depression e Vomiting

d (Rationale Platelet aggregation or clumping together​ increases, leading to the formation of clots which narrow the lumen of the arterial vessel.​ Vasodilation, or opening of the​ arteries, increases blood flow. Fat and fibrin deposits on the arterial walls are called plaque. They cause the artery to become thick and hardened with narrowing of the lumen and decrease blood flow. Spasms of normal or already narrowed arterial vessels narrow the lumen and decrease blood flow.)

The nurse is developing a plan of care for a client with coronary artery disease. Which mechanism does not contribute to decreased blood flow to the​ client's coronary​ arteries? a Increased platelet aggregation b Fat and fibrin deposits on the arterial walls c Spasms of normal or already narrowed arterial vessels d Increased vasodilation of the arteries

d (The nurse would expect a sudden onset of acute chest pain from a coronary artery​ spasm, which is characteristic of Prinzmetal​ angina, in which there is an acute reduction in coronary blood flow. An acute reduction in level of consciousness indicates neurological involvement. A gradual increase in peripheral edema is a sign of heart failure. A gradual increase in systolic blood pressure can have multiple causes.)

You expect what client reaction during a coronary artery​ spasm? a Gradual increase in systolic blood pressure b Acute reduction in level of consciousness c Gradual increase in peripheral edema d Sudden onset of acute chest pain

b (The nurse would expect a sudden onset of acute chest pain from a coronary artery​ spasm, which is characteristic of Prinzmetal​ angina, in which there is an acute reduction in coronary blood flow. An acute reduction in level of consciousness indicates neurological involvement. A gradual increase in peripheral edema is a sign of heart failure. A gradual increase in systolic blood pressure can have multiple causes.)

You expect what client reaction during a coronary artery​ spasm? a Gradual increase in systolic blood pressure b Sudden onset of acute chest pain c Acute reduction in level of consciousness d Gradual increase in peripheral edema

4 (The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern. Focus: Prioritization)

17. You assess a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 144/78 mm Hg 2. Pedal pulses are palpable at +1 3. Left groin has a 3-cm bruised area 4. Apical pulse is 122 beats/min and regular

d (Rationale Stable angina is a predictable form of​ angina, which usually occurs when the work of the heart is increased by physical​ exertion, exposure to​ cold, or stress. Prinzmetal​ (variant) angina occurs unpredictably and often at night. The client is currently experiencing a predictable form of angina. Clinical manifestations of myocardial infarction include pain that is less​ predictable, more​ prolonged, and unrelieved by sublingual nitroglycerin. Clinical manifestations of acute coronary syndrome include pain that is more severe and longer than previously experienced. The pain is not predictable and is unrelieved by sublingual nitroglycerin)

The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. The nurse recognizes that the client is most likely experiencing which​ disorder? a Acute coronary syndrome b Prinzmetal angina c Myocardial infarction d Stable angina

4 (The thrombolytic agent t-Pa administered IV, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hrs after onset of MI. The drug does not reduce coronary artery vasospams; nitrates are used to promote vasodilation. ARrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to opent the oronary artery and re establish a blood supply to the area.)

Alteplase recombinant, or tissue plasminogen activator (t-PA) a thrombolytic enzyme, is administered during the first 6 hrs after onset of MI to: 1. control chest pain 2. reduce coronary artery vasospasm 3. control the arrhythmias associated with MI 4. revascularize the blocked coronary artery

2,5,6 (simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take in the evening, and the nurse should instruct the client that if a dose is missed to take as soon as remembered but not at same time as next dose. it is not necessary to take with food. Do not have to limit greens. DO NOT TAKE WITH GRAPEFRUIT. Also a serious side effect is myopathy, and the client should report muscle pain or tenderness to HCP)

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client, Select all that apply. 1. take once a day in the morning 2. if you miss a dose take it when you remember 3. limit greens such as lettuce in the diet to prevent bleeding 4. be sure to take with food 5. report muscle tenderness or pain to the HCP 6. continue to follow a diet low in saturated fats

1,2,3,4 (When preparing for a cardiac angiogram, the nurse should determine if the client has an allergy to the liquid contrast medium used in the procedure. Contrast dyes contain iodine, and the admin of a dye could lead to an anaphylactic response in clients who are allergic to the dye. An IV infusion will be started before the procedure to admin the contrast dye. The client may experience a flushing sensation, but this is a normal response and does not indicate a life-threatening reaction. The client may receive light sedation, but not an anesthetic as the client must be awake to follow instructions. The client should be instructed to remain still during the procedure.)

When preparing a client for a cardiac angiogram, what actions should the nurse take? Select all that apply: 1. determine if the client has an allergy to liquid contrast material 2. inform the client that an IV infusion will be started before the procedure 3. remind the client to have nothing to eat or drink 8 hrs before the procedure 4. Instruct the client to remain still during the procedure 5. explain that the client will receive fast acting anesthetic

a (Rationale To increase the​ client's blood​ flow, one goal is to prevent the aggregation of platelets in the arteries. Salicylic acid​ (aspirin) is a pharmacological measure to control the aggregation. Statins are used to decrease cholesterol and would be a part of the​ client's protocol unless the client experienced side effects. Analgesics are given for chest​ pain, but do not increase blood flow. Nitrates for angina would increase blood flow. There is no reason to discontinue the use of daily ibuprofen as a means of increasing blood flow to the coronary arteries.)

You are developing a plan of care for a client with coronary artery disease. Which pharmacological treatment would help increase blood flow to the​ client's coronary​ arteries? a Use of salicylic acid daily b Discontinue the use of daily ibuprofen c Use an analgesic to control chest pain d Discontinue the use of statins

1 (The nurse should first obtain VS as changes in the VS will reflect the severity of the sudden drop in cardiac output: decrease in BP ,increase in HR, and increase in RR. 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 contracts 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 and can best be heard when the client is in these positions, not with the client leaning forward. A 12 lead ECG views the electrical activity of the heart: an echocardiogram views valve function)

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 VS 2. draw ABG's 3. evaluate heart sounds with the client leaning forward 4. obtain a 12 lead ECG

d (Rationale Fat and fibrin deposits on the arterial walls are called plaque. They cause the artery to become thick and hardened with narrowing of the lumen and decreased blood flow.Platelet aggregation​ (clumping together)​ increases, not​ decreases, leading to the formation of clots that narrow the lumen of the arterial vessel.​ Vasodilation, or opening of the​ arteries, would increase blood flow. The walls of the arteries become hardened and have decreased​ elasticity, which makes vasodilation more difficult. Spasms of the arterial vessels cause constriction and narrowing of the vessels. Injury that occurs from increased arterial pressure causes an increased risk of the formation of fibrin plaques. The injury does not cause a decrease in blood flow.)

The nurse is developing a plan of care for a client with coronary artery disease. Which mechanism contributes to a decreased blood flow to the​ client's coronary​ arteries? a Increased vasodilation of the arteries b Decreased platelet aggregation c Injury to arterial walls from increased arterial pressures d Fat and fibrin deposits on the arterial walls

1 (Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice. Focus: Delegation)

9. You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN? 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

2,5 (It is important for clients to wear hearing aids to this procedure so that they can hear the questions posed to them by the healthcare team. Chest pain often occurs when the balloon within the stent is inflated and deployed into the coronary artery, It is expected and brief but should still be reported by the client. During the procedure and for a prescribed amount of time after, the client will need to remain flat in bed with the right leg straight, not flexed, to preven bleeding from the access site. The site is not routinely stiched. It is a puncture rather than an incision. The client may be give IV medication to help with comfort, but the client is kept awake to answer questions and to hear instructions and explanations. General anesthesia is not given)

A client is scheduled for insertion of a coronary stent with R groin access. Which teaching points should the nurse include in this clients preoperative teaching plan? Select all that apply 1. If you have a hearing aid, you will need to remove it prior to leaving for the procedure 2. If you have chest pain during the procedure please tell the staff when or if this occurs 3. The stiches on our R groin will be able to be removed in 7-10 days following the procedure 4. You will be given general anesthesia and will be asleep for throughout the procedure 5. You will need to remain flat during the procedure and for 3-6 hrs after 6. You will need to keep your R leg in a flexed position for 1-2 hrs following the procedure

c (Rationale: Prinzmetal's or variant angina is atypical angina that occurs unpredictably (unrelated to activity) and often at night. It is caused by coronary artery spasm with or without an atherosclerotic lesion. This client is at risk for silent ischemia and is associated with a higher relative risk of serious or fatal cardiac events. Stable angina occurs with exertion and is relieved with rest and nitroglycerin tablets. Unstable angina occurs with increasing frequency, severity, and duration. Pain is unpredictable, occurs with decreasing levels of activity or stress, and may occur at rest. It is a precursor to myocardial infarction. The client has classic symptoms of variant angina and so is not experiencing nonanginal pain. Variant angina is prolonged, severe, and occurs at the same time every day, usually in the morning)

A client tells the nurse that the anginal pain is unpredictable but usually occurs at night. The nurse questions the client and family further about precipitating factors at home; however, there does not appear to be any environmental or emotional cause for the pain. The nurse concludes that the client should contact the physician to facilitate admission to the hospital, because the client has which type of angina? a Stable angina b Unstable angina c Variant angina d Nonanginal pain

c (Feedback Rationale: Nausea and anorexia are symptoms of digoxin toxicity. Abnormal sodium or potassium levels or abnormal PT/INR would not explain the client's symptoms and, therefore, are not priorities to assess before notifying the physician. )

A client with coronary artery disease (CAD) has had bypass surgery and is about to be discharged home on several new medications, including digoxin (Lanoxin) and furosemide (Lasix). The client complains of nausea and anorexia. Which action will the nurse do first? a Check the PT/INR. b Call the physician. c Check the digoxin level. d Check the sodium level.

4 (The nurse should instruct the client that correct protocol for using sublingual nitro involves immediate administration when chest pain occurs. Sublingual nitrol appears in the bloodstream within 2-3 mins. and is metabolized within about 10 mins. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 mins, the client should call 911. Although some HCP may recommend taking a second or 3rd tab spaced 5 mins apart and then calling for emergency assist, it is not appropriate to take two tabs at once. Nitro acts within 2-3 mins and the client should not wait 15 mins to take further action. The client should call 911 to obtain emergency help rather than calling the HCP)

How should the nurse instruct the client with unstable angina to use sublingual nitro tabs when chest pain occurs? "sit down and then....: 1. take one tab every 2-5 minutes until the pain stops 2. take one tablet and rest for 15 mins. Call the HCP if pain persists after 15 mins. 3. take one tab; then if pain persists take additional two tablets in 5 mins. Call the HCP if pain persists after 15 mins 4. take one tab. If pain persists after 5 mins call 911