ch 40Care of Patients with Acute Coronary Syndromes

Chest pain that occurs in the days or weeks before an MI

1. f f. Pre-infarction angina

Tissue that is injured but not necrotic

10. j j. Zone of injury

A patient with a CABG has been diagnosed with mediastinitis. What information does the nurse expect to find in the patient's assessment documentation? (Select all that apply.) a. Fever continuing beyond the first 4 days after CABG b. Bogginess of the sternum c. Redness and drainage from suture sites d. Decreased white blood cell count e. Induration or swelling at the suture sites f. Anginal-type chest pain

100. a, b, c, e

A patient had a CABG with a vein graft. To help prevent collapse of the graft, what assess- ment does the nurse perform? a. Auscultate lung sounds b. Monitor for hypotension c. Assess for motion and sensation d. Observe for generalized hypothermia

101. b

2. The nurse is caring for a patient who had a CABG. The nurse pays close attention to which electrolyte levels for this postoperative patient? (Select all that apply.) a. Sodium b. Potassium c. Calcium d. Magnesium e. Phosphorus

102. b, c, d

103. After a CABG, a postoperative patient sud- denly has a decrease in mediastinal drainage, jugular vein distention with clear lung sounds, pulsus paradoxus, and equalizing PAWP and right atrial pressure. Of what does the nurse suspect these are signs? a. Acute MI b. Occlusion at the donor site c. Cardiac tamponade d. Prinzmetal's angina

103. c

4. The nurse coming on duty receives the change of shift report. Which patient is assessed first by the nurse? a. Patient with anxiety, nausea, diaphoresis, and shortness of breath b. Patient with diabetes mellitus and elevated serum lipid levels c. Patient with a friction rub and elevated tem- perature d. Patient with fever, instability of sternum, and increased white blood cell count

104. a

105. The nurse is caring for a patient who had a minimally invasive direct coronary artery bypass (MIDCAB). Which sign/symptom prompts the nurse to immediately contact the health care provider? a. Acute incisional pain b. ST-segment changes in the V leads c. Drainage from the chest tubes d. Problems with coughing

105. b

A patient has discrete, proximal, noncalcified lesions of only one or two vessels. Which pro- cedure is most likely to be recommended for this patient? a. PTCA b. Stress test c. Immediate reperfusion d. Thrombolytic therapy

106. a

he nurse is caring for a patient who had a PTCA. Which postoperative interventions are included in the care for this patient? (Select all that apply.) a. Monitor for acute closure of the vessel . b. Observe for bleeding from the insertion site. c. Assess for reaction to the dye. d. Observe for hypotension, hypokalemia, and dysrhythmias. e. Teach about medications such as aspirin and beta blockers or ACE inhibitors. f. Instruct about lifestyle changes relating to CAD.

107. a, b, c, d, e, f

Treatment of hypothermia, a common prob- lem after CABG surgery, with warming blan- kets is necessary because this condition may cause a patient to be at risk for which condi- tion? a. Hypotension b. Hypertension c. Heart failure d. Loss of consciousness

108. b

Which statement is true about post- pericardiotomy syndrome? a. It is a psychological disorder for which the patient needs emotional support. b. It is generally mild and self-limiting. c. It places the patient at high risk for cardiac tamponade. d. It can be prophylactically managed with an- tibiotics

109. c

Eliminates tremors that can exist with human hands, increases the ability to reach inaccessible sites, and improves depth perception and visual acuity.

110. e e. Robotic heart surgery

17. A patient reports chest pain that is unrelieved with sublingual nitroglycerin. What drug does the nurse administer to this patient next? a. Valium intramuscularly b. Morphine sulfate IV c. Supplemental oxygen d. Chewable aspirin

17. c

18. A patient is hypertensive and continues to have angina despite therapy with beta blockers. The nurse anticipates which type of drug will be prescribed for this patient? a. Calcium channel blocker b. Digoxin c. Angiotensin-converting enzyme (ACE) inhibitor d. Dopamine

18. a

19. The nurse has just given a patient two doses of sublingual nitroglycerin for anginal pain. The patient's blood pressure is typically 130/80 mm Hg. Which finding warrants immediate notifi- cation of the health care provider? a. Patient reports a headache. b. Systolic pressure is 140 mm Hg. c. Systolic pressure is 90 mm Hg. d. Anginal pain continues but is somewhat relieved.

19. c

Necrosis or cell death

2. bb infarction

Studies have shown that endothelial dysfunction may be the cause of CAD in women

24. T

Postmenopausal women in their 70s have a higher incidence of MI than me

25. F; have an incidence of MI that equals that of men

All three layers of heart are involved

3. gg. Transmural myocardial infarction (MI)

36. What are indicators of metabolic syndrome, which increases the risk for coronary heart dis- ease? (Select all that apply.) a. Triglyceride level of 170 mg/dL b. HDL cholesterol level of 45 mg/dL in a male c. HDL cholesterol level of 45 mg/dL in a fe- male d. Blood pressure of 130/86 mm Hg e. Fasting blood sugar level of 120 mg/dL

36. a, b, d, e

38. A patient is trying to make dietary modifica- tions to reduce lipid levels. The patient would like information about omega-3 fatty acid food sources. What best source does the nurse rec- ommend? a. Flaxseed b. Flaxseed oil c. Fish d. Walnuts

38. c

Tobacco use, especially cigarette smok- ing, accounts for over 90% of deaths from CAD.

39. F; accounts for over one- third of deaths

First angina symptoms, usually after exertion or other increased demands on the hea

4. d d. New-onset angina

A person who stops smoking may de- crease the risk of CAD by as much as 80% in 1 year.

40. T

Reducing the tar and nicotine content of the cigarettes smoked reduces the risk of CAD.

41. F; does not reduce the risk of CAD

Less active, less fit people have a 30% to 50% greater risk of developing high blood pressure which predisposes to CAD.

42. T

Physical activity increases collateral circulation and reduces the size of ex- isting plaques.

43. F; does not increase

A patient comes to the walk-in clinic reporting left anterior chest discomfort with mild short- ness of breath. The patient is alert, oriented, diaphoretic, and anxious. What is the priority action for the nurse? a. Obtain a complete cardiac history to in- clude a full description of the presenting symptoms. b. Place the patient in Fowler's position and start supplemental oxygen. c. Instruct the patient to go immediately to the closest full-service hospital. d. Immediately alert the physician and estab- lish IV access.

44. b

A patient reports having chest discomfort that started during exercise. The patient is currently pain-free, but "is concerned." What questions does the nurse ask to assess the patient's pain episode? (Select all that apply.) a. "When did the pain start and how long did it last?" b. "What were you doing when the pain started?" c. "What did you do to alleviate the pain?" d. "How did you feel about the pain?" e. "Did the pain radiate to other locations?" f. "Was the pain sharp and stabbing?" g. "On a scale of 0 to 10 with 10 as the worst pain, what number would you use to cat- egorize the pain?"

45. a, b, c, e, g

A patient is currently pain- and symptom-free, but reports having intermittent episodes of chest pain over the past week. The nurse asks about which associated symptoms? (Select all that apply.) a. Nausea b. Diarrhea c. Diaphoresis d. Dizziness e. Joint pain f. Palpitations g. Shortness of breath

46. a, c, d, f, g

47. The emergency department (ED) nurse is as- sessing an 86-year-old patient with acute con- fusion, increased respiratory rate, anxiety, and chest pain. The nurse finds a respiratory rate of 36/min with crackles and wheezes on ausculta- tion. How does the nurse interpret these find- ings? a. Left sided-heart failure b. Atypical angina c. CAD d. Unstable angina

47. a

48. The nurse is assessing a middle-aged woman with diabetes who denies any history of known heart problems. However, on auscultation of the heart the nurse hears an S4 heart sound. The nurse alerts the physician and obtains an order for which diagnostic test? a. Blood glucose level b. ECG c. Chest x-ray d. Echocardiogram

48. b

"Strangling of the chest"

5. cAngina pectoris .

he ED nurse caring for a patient with severe chest pain and ECG changes gives supplemen- tal oxygen to the patient as ordered. Which other medications does the nurse anticipate giving to this patient? (Select all that apply.) a. IV nitroglycerin b. Beta blocker c. IV morphine d. Oral aspirin e. ACE inhibitor

53. a, b, c, d

54. The nurse is caring for a hospitalized patient being treated initially with IV nitroglycerin. What intervention does the nurse include in this patient's care? a. Increase the dose rapidly to achieve pain relief. b. Assist the patient to the bathroom as need- ed. c. Monitor blood pressure continuously. d. Elevate the head of the bed to 90 degrees

54. c

55. A patient is currently on oxygen therapy for chest pain. The pulse oximetry is on and sig- nals an abrupt drop from 93% to 89%. What is the priority action for the nurse? a. Alert the Rapid Response Team. b. Troubleshoot the oxygen setup and the pulse oximeter sensor. c. Increase the oxygen flow rate and elevate the head of the bed. d. Advise the patient to watch the monitor and take several deep breaths.

55. b

56. The home health nurse receives a call from a patient with CAD who reports having new on- set of chest pain and shortness of breath. What does the nurse direct the patient to do? a. Rest quietly until the nurse can arrive at the house to check the patient. b. Chew 325 mg of aspirin and immediately call 911. c. Use supplemental home oxygen until symptoms resolve. d. Take three nitroglycerin tablets and have family drive the patient to the hospital.

56. b

7. A patient is newly diagnosed with cardiovascu- lar disease. What psychosocial reactions does the nurse assess for? (Select all that apply.) a. Fear b. Anxiety c. Anger d. Suspicion e. Denial f. Euphoria g. Depression

57. a, b, c, e, g

Which drug is given within 1 to 2 hours of an MI, if the patient is hemodynamically stable, to help the heart to perform more work without ischemia? a. Vasodilators, such as sublingual or spray nitroglycerin (NTG) b. Beta-adrenergic blocking agents, such as metoprolol (Lopressor) c. Antiplatelet agents, such as clopidogrel (Plavix) d. Calcium channel blockers, such as diltia- zem (Cardizem)

58. b

Which statements are true about the use of thrombolytic agents for a patient with an acute MI? (Select all that apply.) a. A patient who has received a thrombolytic agent must be continuously monitored be- fore and after the medication is given. b. Thrombolytic therapy is indicated for chest pain of longer than 30 minutes duration that is unrelieved by other medications. c. There are no contraindications to throm- bolytic therapy if the patient is having an acute MI as evidenced by cardiac enzymes and ECG. d. Bleeding is a risk for patients receiving thrombolytic therapy. e. The nurse need only monitor clotting stud- ies of the patient who has received throm- bolytic therapy. No further assessment is needed.

59. a, b, d

Scar tissue permanently changes the size and shape of the entire left ven- tricle

6. hh. Ventricular remodeling

he health care provider is considering use of thrombolytic therapy for a patient. What is the criterion for this therapy? a. Chest pain of greater than 15 minutes' du- ration that is unrelieved by nitroglycerin b. Indications of transmural ischemia and injury as shown by the ECG c. Ventricular dysrhythmias shown on the cardiac monitor d. History of chronic, severe, poorly con- trolled hypertension

60. b

A patient is being evaluated for thrombolytic therapy. What are contraindications for this procedure? (Select all that apply.) a. Ischemic stroke within 3 months b. Pregnancy c. Surgery within the last 10 days d. Major trauma in the last 12 months e. Intracranial hemorrhage f. Malignant intracranial neoplasm g. Deep vein thrombosis

61. a, b, c, e, f

62. A patient has received thrombolytic therapy for treatment of acute MI. What are post- administration nursing responsibilities for this treatment? (Select all that apply.) a. Document the patient's neurologic status. b. Observe all IV sites for bleeding and pa- tency. c. Monitor WBC count and differential. d. Monitor clotting studies. e. Monitor hemoglobin and hematocrit. f. Test stools, urine, and emesis for occult blood.

62. a, b, d, e, f

A patient is receiving beta-blocker therapy for treatment of MI. What does the nurse monitor for in relation to this therapy? (Select all that apply.) Tachycardia b. Hypotension c. Decreased level of consciousness d. Chest discomfort e. Increased urinary output

63. b, c, d

A patient is being treated with medication therapy following an acute MI. The nurse ques- tions the order for which type of drug? b. a. Calcium channel blocker b. Beta-blocker c. Angiotensin-converting enzyme (ACE) in-hibitor d. Angiotensin receptor blocker (ARB)

64. a

A patient with angina is taking calcium chan- nel blockers. What does the nurse monitor the patient for? a. Wheezes b. Hypotension c. Bradycardia d. Forgetfulness

65. b

Which diagnostic test is performed after an- gina or MI to determine cardiac changes that are consistent with ischemia, to evaluate medi- cal interventions, and to determine whether invasive intervention is necessary? a. Stress test b. ECG c. Echocardiography d. Chest x-ray

66. a

he nurse is monitoring a patient who had fibrinolytics and percutaneous transluminal coronary angioplasty (PTCA). What is an in- dication that the clot has lysed and the artery reperfused? a. Abrupt increase of pain or discomfort b. Sudden onset of ventricular dysrhythmias c. Appearance of ST-segment depression d. Obvious T wave inversion

67. b

A patient has had an MI. The nurse anticipates which type of drug will be prescribed within 48 hours to prevent the development of heart failure? a. Calcium channel blockers b. ACE inhibitor c. Beta blockers d. Digoxin

68. b

he nurse has identified the priority problem of Activity Intolerance for a patient who had an acute MI. What is the best expected out- come for this patient? Patient will walk at least 200 feet four times a day without chest discomfort or shortness of breath. Patient will name three or four activities that will not cause shortness of breath or chest pain. Nurse will teach the patient to exercise and to take the pulse if symptoms of shortness of breath or pain occur. Nurse will assist the patient with ADLs un- til shortness of breath or pain resolves

69. a Patient will walk at least 200 feet four times a day without chest discomfort or shortness of breath.

Tissue that is oxygen-deprive

7. kk. Zone of ischemia

70. A patient is in the acute phase (phase 1) of cardiac rehabilitation. Which task is best to delegate to the unlicensed assistive personnel (UAP)? a. Assist the patient to ambulate approxi- mately 200 feet three times a day. b. Assist the patient with ambulation to the bathroom. c. Assess heart rate, blood pressure, respira- tory rate, and fatigue with each higher level of activity. d. Assist the patient into the bathtub.

70. b

71. A patient in the cardiac rehabilitation facility is having difficulty coping with the changes in her health status. Which statement by the pa- tient is the strongest indicator of ineffective or harmful coping? a. "I don't mind going to therapy, but I'm not sure if I'm getting any benefit from it." b. "I'll take the pills and just do whatever you want me to do." c. "I don't want to go to therapy; I had a bad experience yesterday with the therapist." d. "I know I need to talk about going home soon, but could we discuss it later?"

71. c

2. A post-MI patient in phase 1 cardiac rehabili- tation is encouraged to perform which activ- ity? a. Range-of-motion exercises b. Modified weight training c. Stair climbing d. Jogging

72. a

73. The nurse is caring for a patient admitted for an inferior wall MI. The patient develops heart block with bradycardia. Because the patient's pulse rate is low and the blood pressure is un- stable, which procedure is the nurse prepared to assist with? a. Temporary pacemaker b. Defibrillation c. 16-lead ECG d. Percutaneous intervention

73. a

he nurse is contacted by the cardiac monitor- ing technician who says a patient is having a dysrhythmia. What does the nurse do next? a. Identify the dysrhythmia. b. Administer antidysrhythmic medication. c. Evaluate for chest pain or discomfort. d. Double-check the lead placement.

74. c

The nurse is evaluating a patient with CAD. What is an expected patient outcome that demonstrates hemodynamic stability? a. Blood pressure and pulse within range and adequate for metabolic demands b. An increase in urine output c. Regular P waves and no abnormal heart sounds d. Verbal understanding of risk factors and need for compliance

75. a

The nurse is assessing a patient at risk for left ventricular failure and inadequate organ per- fusion. Which signs and symptoms signal de- creased cardiac output? (Select all that apply.) a. Change in orientation or mental status b. Urine output less than 1 mL/kg (2.2 lbs)/hr or less than 30 mL/hr c. Hot, dry skin with flushed appearance d. Cool, clammy extremities with decreased or absent pulses e. Unusual fatigue f. Recurrent chest pain

76. a, b, d, e, f

77. The nurse is reviewing medication orders for several cardiac patients. There is an order for beta-adrenergic blocking agent metoprolol XL (Toprol XR) once a day. This drug order is most appropriate for which class of patients according to the Killip classification system? a. All classes b. Class I only c. Class II and III d. Class IV only

77. c

78. The nurse is caring for a patient with an ante- rior wall MI (AWMI). The patient develops tachycardia, hypotension, urine output of 10 mL/hr, cold and clammy skin with poor pe- ripheral pulses, and agitation. What does the nurse suspect in this patient? a. Ventricular dysrhythmia b. Cardiogenic shock c. Post-pericardiotomy syndrome d. Acute coronary syndrome

78. b

79. The nurse is assessing a cardiac patient and finds a paradoxical pulse, clear lungs, and jugular venous distention that occurs when the patient is in a semi-Fowler's position. What are these findings consistent with? a. Right ventricle failure b. Unstable angina c. CAD d. Valvular disease

79. a

Around the initial area of infarction

8. i i. Zone of necrosis

81. A patient continues to have chest pain despite compliance with medical therapy. The nurse teaches the patient about which diagnostic test? a. Left-sided cardiac catheterization with coronary angiogram b. PTCA c. Coronary artery bypass grafting (CABG) d. Stent placement in coronary artery

81. a

82. Immediate reperfusion is an invasive interven- tion that shows some promise for managing which disorder? a. Right ventricular failure b. Metabolic syndrome c. Cardiogenic shock d. Acute coronary syndrome

82. c

83. A patient is scheduled to have PTCA. The nurse anticipates that an initial dose of which medication will be given before the procedure? a. Clopidogrel (Plavix) b. Nitroglycerin (Nitrostat) c. Isosorbide mononitrate (Imdur) d. Carvedilol (Coreg)

83. a

84. A patient has angina and is scheduled for PTCA. Based on outcomes of the PTCA, the nurse prepares the patient for immediate transfer to undergo which procedure? a. Intra-aortic balloon pump b. CABG c. Cardiac catheterization d. Carotid endarterectomy

84. b

85. The nurse is caring for a patient who had PTCA. Which symptom indicates acute closure of the vessel and therefore warrants immediate notification of the health care pro- vider? a. Chest pain b. Hyperkalemia c. Bleeding at the insertion site d. Cough and shortness of breath

85. a

86. Which patients may be potential candidates for CABG? (Select all that apply.) a. Patient with angina and greater than 50% occlusion of left main coronary artery that cannot be stented b. Patient with unstable angina with moder- ate vessel disease appropriate for stenting c. Patient with valvular disease d. Patient with coronary vessels unsuitable for PTCA e. Patient with acute MI responding to thera- py f. Patient with signs of ischemia or impend- ing MI after angiography or PTCA

86. a, c, d, f

87. A patient is trying to decide whether to con- sent to a CABG. What information does the nurse give the patient? (Select all that apply.) a. CABG improves the quality of life for most patients. b. Most patients are pain-free at 1 year after surgery. c. 70% of patients will remain permanently pain-free. d. Most patients have a decreased quality of life after 15 years. e. Most patients remain pain-free 5 years after surgery, but some patients experience some pain after 5 years.

87. a, b, e

88. A patient is having an elective CABG with a minimally invasive surgical technique. What does the nurse include in the preoperative teaching? a. Prevention of edema and scarring at the harvest site b. Protection and splinting of the chest inci- sion while coughing c. Availability of analgesics if needed, but probably unnecessary d. Limitation of ambulation for several days after the procedure

88. b

A patient is having a CABG with the tradi- tional surgical procedure. What does the nurse include in the preoperative teaching? (Select all that apply.) a. Expect a small 1- to 2-inch incision on the leg. b. There will be a sternal incision. c. Expect one, two, or three chest tubes. d. An indwelling urinary catheter will be placed. e. An endotracheal tube will prevent talking.

89. b, c, d, e

Chest pain or discomfort from coro- nary artery spasm; typically occurs after rest

9. ee. Variant (Prinzmetal's) angina

he intensive care nurse is caring for a patient who has just had a CABG. The nurse notes that the patient has edema. In order to adjust fluid administration, the nurse collects which additional information and then consults the health care provider? (Select all that apply.) a. Blood pressure b. PAWP c. Skin turgor d. Cardiac output e. Blood loss f. Urine output

90. a, b, d, e, f

A potassium bolus of 80 mEq mixed in 100 mL of IV solution at a rate of 40 mEq/hr is ordered for a patient in the critical care unit. What does the nurse do next? a. Contact the health care provider because the order exceeds the recommended amount. b. Give the infusion; the order exceeds the recommended amount, but is within ac- ceptable standards of practice for critical care patients. c. Contact the health care provider because even though the dosage is acceptable, the rate is too fast. d. Consult with the pharmacist because even though the rate is acceptable, the mixture is too concentrated.

91. b

he intensive care nurse is caring for a patient who has just had a CABG. The patient has a systolic blood pressure of 80 mm Hg. What is the primary concern related to this patient's hypotension? a. It is associated with warm cardioplegia. b. It may result in the collapse of the graft. c. It will result in acute tubular necrosis. d. It is related to mechanical ventilation.

92. b

Following a CABG, a patient has a body tem- perature below 96.8° F (36° C). What measures (if any) should be used to rewarm the patient? a. Infuse warm IV fluids. b. Do not rewarm; cold cardioplegia is pro- tective. c. Place the patient in a warm fluid bath. d. Use lights or thermal blankets.

93. d

94. The intensive care nurse is caring for a patient who has just had a CABG. What does the nurse do to assess for postoperative bleeding? a. Measure mediastinal and pleural chest tube drainage at least hourly and report drainage amounts over 150 mL/hr to the surgeon. b. Measure mediastinal and pleural chest tube drainage at least once a shift and re- port drainage amounts over 50 mL/hr to the surgeon. c. Assess the dressing over the sternal site every 4 hours and reinforce the dressing with sterile gauze as needed. d. Assess the donor site every 4 hours and report serous drainage and increasing pain to the surgeon

94. a

Following a CABG, a patient in the ICU on a mechanical ventilator suddenly decompen- sates. The health care provider makes a diagno- sis of cardiac tamponade. The nurse prepares the patient for which emergency procedure? Chest tube b. Sternotomy c. Pericardiocentesis 100. d. Thoracentesis

95. b

96. The nurse is assessing a patient who had a CABG. Which finding is a permanent deficit that is associated with an intraoperative stroke? a. Decreased level of consciousness that re- solves when body temperature is normal b. Arousal from anesthesia which takes sev- eral hours c. Inability to speak clearly and coherently immediately after surgery d. Generalized seizure activity

96. d

97. A patient reports pain after a CABG. Which statement by the patient suggests that the pain is related to the sternotomy and not anginal in origin? a. "The pain goes down my arm or some- times into my jaw." b. "My pain increases when I cough or take a deep breath." c. "The nitroglycerin helped to relieve the pain." d. "I feel nausea and shortness of breath when the pain occurs."

97. b

A patient with a CABG is transferred from the ICU to the intermediate care unit. Which ac- tivity does the nurse assist the patient with? a. Ambulating 25 to 100 feet three times a day as tolerated b. Turning the patient every 2 hours for the first 48 hours c. Dangling and turning every 2 hours for at least 24 hours d. Coughing and deep-breathing three times a day

98. a

A patient had CABG with the radial artery used as a graft. The nurse performs which as- sessment specific to this patient? a. Check the blood pressure every hour on the unaffected arm or use the legs. b. Check the fingertips, hand, and arm for sensation and mobility every shift. c. Assess hand color, temperature, ulnar/ra- dial pulses, and capillary refill every hour initially. d. Note edema, bleeding, and swelling at the donor site, which are expected.

99. c

0. A patient is admitted for unstable angina. The patient is currently asymptomatic and all vital signs are stable. Which position does the nurse place the patient in? a. Any position of comfort b. Supine c. Sitting in a chair d. Fowler's

a

33. Which patient has the highest risk for death because of ventricular failure and dysrhyth- mias related to damage to the left ventricle? a. Patient with an anterior wall MI (AWMI) b. Patient with a posterior wall MI (PWMI) c. Patient with a lateral wall MI (LWMI) d. Patient with an inferior wall MI (IWMI)

a

34. A patient had an IWMI. The nurse closely monitors the patient for which dysrhythmia associated with IWMI? a. Bradycardia and second-degree heart block b. Premature ventricular contractions c. Supraventricular tachycardia d. Atrial fibrillation

a

37. A patient has high risk for CAD. What is the goal for this patient's LDL level? a. Less than 70 mg/dL b. Less than 100 mg/dL c. Below 135 mg/dL d. Below 200 mg/dL

a

Place the steps for administering sublingual nitroglycerin to a patient with episodes of an- gina in the correct order using the numbers 1 through 5. In 5-minute increments, a total of three doses may be admin- istered in an attempt to relieve angina pain. For no relief after dosing, im- mediately inform the health care provider and prepare the patient for transfer to a specialized unit. Hold the tablet under the tongue so the tablet can dissolve. After 5 minutes, recheck pain intensity and vital signs. If the patient is experiencing some, but not complete, relief and vital signs remain stable, an- other tablet may be used.

a 4 b. 5 c. 1 d. 2 e. 3 Hold the tablet under the tongue so the tablet can dissolve. After 5 minutes, recheck pain intensity and vital signs. If the patient is experiencing some, but not complete, relief and vital signs remain stable, an- other tablet may be used. In 5-minute increments, a total of three doses may be admin- istered in an attempt to relieve angina pain. For no relief after dosing, im- mediately inform the health care provider and prepare the patient for transfer to a specialized unit.

Indicate whether the characteristics listed be- low are angina (A) or myocardial infarction (MI). a Pain is precipitated by exertion or stress. b Pain occurs without cause, usu- ally in the morning. c Pain is relieved only by opioids. d Pain is relieved by nitroglycerin or rest. e Nausea, diaphoresis, feelings of fear, and dyspnea may occur. f There are few associated symp- toms. g Pain lasts less than 15 minutes. h Pain lasts 30 minutes or more. i Pain radiates to left arm, back, or jaw.

a A b MI c MI d A e MI f A g A h MI i MI

27. A patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST elevation MI (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in the patient? (Select all that apply.) a. Positive troponin markers b. Chronic stable angina c. Non-ST elevation MI (non-STEMI) d. Cardiac dysrhythmia e. Heart failure

a,c

49. A middle-aged African-American patient with no known medical problems has acute onset chest pain and dyspnea. In order to rule out acute MI, the nurse obtains orders for which diagnostic tests? (Select all that apply.) a. Myoglobin b. Triglyceride levels and C-reactive protein c. Chest x-ray, arterial blood gas d. Pulmonary function testing e. Total serum cholesterol, low-density lipo- protein, high-density lipoprotein f. Troponin T and I g. Creatine kinase-MB, myoglobin

a,f, g

Occurs when insufficient oxygen is supplied to meet the requirements of the myocardium

aa ischemia

Cardiopulmonary bypass (CPB) is not required.

aa. Minimally invasive direct coronary artery by- pass (MIDCAB)

14. A patient has been admitted for acute angina. Which diagnostic test identifies if the patient will benefit from further invasive management after acute angina or an MI? a. Exercise tolerance test b. Cardiac catheterization c. Thallium scan d. Multigated angiogram (MUGA) scan

b

30. The nurse is auscultating the heart of a patient who had an MI. Which finding most strongly indicates heart failure? a. Murmur b. S3 gallop c. Split S1 and S2 d. Pericardial friction rub

b

50. A patient had severe chest pain several hours ago but is currently pain-free and has a normal ECG. Which statement by the patient indicates a correct understanding of the significance of the ECG results? a. "I'll go home and make an appointment to see my family doctor next week." b. "The ECG could be normal since I am cur- rently pain-free." c. "A normal ECG means I am okay." d. "I have always had a strong heart, low blood pressure, and a normal ECG."

b

People should seek treatment for symptoms of MI rather than delay because physical changes will occur approximately how many hours af- ter an infarction? a. 3 b. 6 c. 12 d. 24

b

Patient has one or two very small inci- sions in the leg or arm

b b. Endovascular (endoscopic) vessel harvesting (EVH)

29. The nurse is caring for a patient admitted with unstable angina and elevated lipid levels. What does the nurse include in teaching this patient about his or her elevated lipid levels? (Select all that apply.) a. Begin a vigorous exercise program. b. Avoid trans-fatty acids. c. Reduce intake of saturated fats. d. Monitor the amount of cholesterol ingest- ed, staying below 200 mg/day. e. Decrease weight.

b, c, d, e

16. A patient with angina is prescribed nitroglyc- erin tablets. What information does the nurse include when teaching the patient about this drug? (Select all that apply.) a. "If one tablet does not relieve the angina after 5 minutes, take two pills." b. "You can tell the pills are active when your tongue feels a tingling sensation." c. "Keep your nitroglycerin with you at all times." d. "The prescription should last about 6 months before a refill is necessary." e. "If pain doesn't go away, just wait; the medication will eventually take effect." f. "The medication can cause a temporary headache or a flushed face."

b, c, f,

12. The nurse is interviewing a patient reporting chest discomfort that occurs with moderate to prolonged exertion. The patient describes the pain as being "about the same over the past several months and going away with nitroglyc- erin or rest." Based on the patient's description of symptoms, what does the nurse suspect in this patient? (Select all that apply.) a. Chronic stable angina (CSA) b. Unstable angina c. Acute coronary syndrome (ACS) d. Acute myocardial infarction (MI) e. Coronary artery disease (CAD

b, e

The ED nurse is caring for a patient with acute pain associated with MI. What are the purpos- es of collaborative management that address the patient's pain? (Select all that apply.) a. Return the vital signs and cardiac rhythm to baseline, so the patient can resume ac- tivities of daily living. b. Prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply. c. Aggressively diagnose and treat life- threatening cardiac dysrhythmias and re- store pulmonary wedge pressure. d. Closely monitor the patient for accompa- nying symptoms such as nausea and vom- iting or indigestion. e. Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply.

b, e

32. A patient has heart failure related to MI. What intervention does the nurse plan for this pa- tient's care? a. Administering digoxin (Lanoxin) 1.0 mg as a loading dose and then daily b. Infusing IV fluids to maintain a urinary output of 60 mL/hr c. Titrating vasoactive drugs to maintain a sufficient cardiac output d. Observing for such complications as hy- pertension and flushed, hot skin

c

80. The intensive care nurse is monitoring a pa- tient with a right ventricular MI. The pulmo- nary artery wedge pressure (PAWP) reading is 30 mm Hg. What does the nurse do next? a. Increase the IV fluid rate to 200 mL/hour. b. Auscultate the lungs to assess for left-sided heart failure. c. Perform an ECG using right-sided precor- dial leads. d. Place the patient in semi-Fowler's position.

c

Which statement about silent MI is correct? a. In a silent MI, the patient does not have any pain, so there is less myocardial dam- age. b. Diabetic patients are prone to silent MI that goes undiagnosed without complica- tions. c. Silent MI increases the incidence of new coronary events. d. In silent MI, the myocardium is oxygen- ated by increased collateral circulation.

c

13. A patient with a history of angina is admitted for surgery. The patient reports nausea, pres- sure in the chest radiating to the left arm, ap- pears anxious, skin is cool and clammy, blood pressure is 150/90 mm Hg, pulse is 100, and respiratory rate is 32. What are the priorities of nursing care for this patient? (Select all that ap- ply.) a. Relieve anxiety b. Maintain NPO status c. Improve coronary perfusion d. Improve coronary oxygenation e. Relieve chest pain

c, d, e

Creates channels that will eventually allow oxygenated blood to flow during diastole from the left ventricle to nour- ish the muscle.

cc. Transmyocardial laser revascularization

15. The nurse is talking to a patient with angina about resuming sexual activity. Which state- ment by the patient indicates a correct under- standing about the effects of angina on sexual activity? a. "I won't be able to resume the same level of physical exertion as I did before I had chest pain." b. "I will discuss alternative methods with my partner since I will no longer be able to have sexual intercourse." c. "If I cannot walk a mile, I am not strong enough to resume intercourse." d. "I can resume sexual activity after a rest period."

d

35. The nurse is giving a community presentation about heart disease. Because 95% of sudden cardiac arrest victims die of ventricular fibrilla- tion before reaching the hospital, which teach- ing point does the nurse emphasize? a. Controlling alcohol consumption and quitting cigarette smoking b. Modifying risk factors such as diet and weight, and blood pressure medication compliance c. Recognizing the difference between chron- ic stable angina and unstable angina d. Learning to operate the automatic external defibrillators (AEDs) in the workplace

d

31. Which diagnostic tests are used to assess myo- cardial damage caused by an MI? (Select all that apply.) a. Positive chest x-ray b. Creatine kinase (CK) elevation c. ECG: ST depression d. CK-MB isoenzymes elevation e. Troponin I isoenzyme elevation

d, e

Procedure in which open heart sur- gery is performed without the use of a heart-lung bypass machine.

dd. Off-pump coronary artery bypass (OPCAB)

Ischemia that occurs with angina is limited in duration and does not cause permanent damage of myocardial tis- sue

t

Many patients suffering sudden car- diac arrest die before reaching the hos- pital due to ventricular fibrillation.

t