CHAPTER 38: CARE OF PATIENTS WITH ACUTE CORONARY SYNDROMES

2. The nurse is assessing a client who has a history of stable angina. The client describes a recent increase in the number of attacks and in the intensity of the pain. Which question does the nurse ask to assess the client's change in condition? a. "How many cigarettes do you smoke daily?" b. "Do you have pain when you are resting?" c. "Do you have abdominal pain or nausea?" d. "How frequently are you having chest pain?"

ANS: B An increase in the number of anginal attacks and an increase in the intensity of pain characterize unstable angina. Chest pain or discomfort also occurs at rest. The nurse should assess for this characteristic of unstable angina. The other questions would not be helpful in assessing for unstable angina.

21. The nurse is assessing a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) and is ordered to receive an IV infusion of abciximab (ReoPro). Which clinical manifestation does the nurse monitor for in this client? a. Bleeding b. Joint pain c. Pedal edema d. Excessive thirst

ANS: A Administration of glycoprotein (GP) IIa/IIIb inhibitors is common during the first few hours after PTCA. The nurse should monitor the client closely for bleeding and hypersensitivity reactions, which can include angioedema, urticaria, and even anaphylaxis. The other manifestations are not associated with the administration of GP IIa/IIIb inhibitors.

7. The nurse evaluates diagnostic results for a client who has chest pain. Which laboratory test is most specific for acute coronary syndromes? a. Troponin markers b. Serum lactate dehydrogenase (LDH) c. Serum myoglobin d. Creatine kinase (CK)-MB isoenzyme

ANS: A Although all these laboratory tests are appropriate to confirm or rule out a myocardial infarction, the one most specific for acute coronary syndromes is troponin T. When elevated, it serves to identify the development of unstable angina, subendocardial MI, or MI.

17. The nurse is teaching a client who is prescribed a calcium channel blocking agent after a percutaneous transluminal coronary angioplasty (PTCA). Which instruction does the nurse include in this client's teaching? a. "Change position slowly." b. "Avoid crossing your legs." c. "Weigh yourself daily." d. "Decrease salt intake."

ANS: A Calcium channel blocking agents cause systemic vasodilation and postural (orthostatic) hypotension. The client should avoid crossing legs, should weigh daily, and should decrease salt intake, but these are not associated with teaching for a calcium channel blocker.

12. The nurse is administering thrombolytic therapy to a client who had a myocardial infarction. Which intervention does the nurse implement to reduce the risk of complications in this client? a. Administer prescribed heparin. b. Apply ice to the injection site. c. Place the client in Trendelenburg position. d. Instruct the client to take slow deep breaths.

ANS: A Following clot lysis, large amounts of thrombin are released, increasing the risk of vessel reocclusion. To maintain vessel patency, IV or low-molecular-weight heparin and aspirin are prescribed. The other interventions are not appropriate for this client.

16. The nurse is caring for a client who had a myocardial infarction. The client develops increased pulmonary congestion; an increase in heart rate from 80 to 102 beats/min; and cold, clammy skin. Which action does the nurse implement before notifying the health care provider? a. Administer oxygen. b. Increase the IV flow rate. c. Place the client in supine position. d. Prepare the client for surgery.

ANS: A The nurse recognizes these manifestations as impending cardiogenic shock. Oxygen is needed to prevent further deterioration. The provider is notified immediately so that efforts can be made to reverse this condition because it has a mortality rate of 65% to 100%. IV fluids would enhance the respiratory edema. The client should be placed in high Fowler's position to assist with respirations. The client does not need surgery.

19. The nurse is teaching a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching? a. "I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain." b. "Even if I have not used any of the nitroglycerin from one refill, I get another refill every 3 months." c. "If I still have chest pain after I have taken 3 nitroglycerin tablets, I will go to the hospital." d. "When my nitroglycerin tablet tingles under my tongue, I know that it is strong enough to work."

ANS: A The shelf life of nitroglycerin is short. It deteriorates quickly in the presence of light or moisture. A clear plastic bag does not provide sufficient protection to ensure potency of the drug. Nitroglycerin tablets should be replaced every 3 to 5 months. If chest pain continues after taking nitroglycerin, the client should call EMS. Nitroglycerin is given sublingual.

4. A client is hospitalized after a myocardial infarction. Which hemodynamic parameters does the nurse correlate with cardiogenic shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased mean arterial pressure (MAP) d. Decreased MAP e. Increased afterload f. Decreased afterload

ANS: A, D, E Myocardial infarction (MI) is a major cause of direct pump failure. With MI, cardiac output and MAP are decreased and afterload is increased. The other parameters do not correlate with pump failure.

1. The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease (CAD) does the nurse include in the education? (Select all that apply.) a. Cigarette smoking b. Use of alcohol c. Insomnia d. Hypertension e. Obesity f. Depression

ANS: A, D, E Teach about lifestyle risk factors of CAD, such as obesity, smoking, positive family history, cholesterol management, and diagnosis and treatment of hypertension.

8. While evaluating a client's electrocardiogram (ECG) before surgery, the preoperative nurse identifies large, wide Q waves. What is the nurse's best interpretation of this finding? a. An acute myocardial infarction is occurring. b. The client had a myocardial infarction in the past. c. The ventricles are enlarged and failing. d. The ECG is a common variation of normal sinus rhythm.

ANS: B A wide and large Q wave develops as a result of myocardial infarction and necrotic ventricular cells that do not conduct electrical impulses. This change is usually permanent. When it appears alone, it indicates a past MI. The other interpretations are not correct.

14. The nurse is assisting a client to walk in the hall on the third day after a myocardial infarction. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity? a. Facial flushing b. Onset of chest pain c. Heart rate increase of 10 beats/min at completion of the activity d. Systolic blood pressure increase of 10 mm Hg at completion of the activity

ANS: B Chest pain on ambulation indicates poor tolerance to activity and is an indication that the heart is not ready for progression. The other manifestations indicate that the client is tolerating the activity.

23. The nurse is assessing a client who is 6 hours postoperative from coronary artery bypass graft surgery. The client's mediastinal tubes are not draining. Which action does the nurse implement at this time? a. Replace the drainage tubing. b. Check for kinks in the tubing. c. Irrigate the tubing with normal saline. d. Document the finding.

ANS: B Sudden cessation of mediastinal drainage could result in cardiac tamponade from accumulation of blood around the heart. If the tubing is kinked, this can be addressed quickly. If the tubing is not kinked, immediate notification of the provider is required. The other actions do not correctly address the problem.

22. The nurse is assessing a client who has a serum potassium level of 4.5 mEq/L after coronary artery bypass graft (CABG) surgery. Which action does the nurse take? a. Notify the health care provider. b. Document the finding. c. Administer prescribed diuretics. d. Administer prescribed potassium replacements.

ANS: B The client who is postoperative from a CABG is at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy. Therefore, the potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. This value is at the desired level for this client. The finding requires documentation only.

1. The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina? a. Chest discomfort at rest and inability to tolerate mowing the lawn b. Chest discomfort when mowing the lawn and subsiding with rest c. Indigestion and a choking sensation when mowing the lawn d. Jaw pain that radiates to the shoulder after mowing the lawn

ANS: B The client with stable angina reports chest discomfort that occurs with moderate, prolonged exertion. This discomfort is typically relieved with nitroglycerin or rest. The other experiences do not correlate with stable angina.

3. The nurse administers intravenous dobutamine (Dobutrex) to a client who has heart failure. Which clinical manifestations indicate that the client's status is improving? (Select all that apply.) a. Decreased heart rate b. Increased heart rate c. Increased contractility d. Decreased contractility e. Increased respiratory rate

ANS: B, C Dobutamine is a positive inotropic agent that works by stimulating beta-adrenergic receptor sites. The result of this stimulation is an increase in the rate and force of the myocardial contraction. Dobutamine has no effect on respiratory rate.

2. The nurse is monitoring the electrocardiogram (ECG) of a client who has a myocardial infarction. Which changes does the nurse expect to see in the ECG tracing? (Select all that apply.) a. ST-segment depression b. T-wave inversion c. Normal Q waves d. ST-segment elevation e. T-wave elevation f. Abnormal Q wave

ANS: B, D, F When myocardial infarction occurs, the changes usually seen on an ECG tracing are ST-segment elevation, T-wave inversion, and an abnormal Q wave.

18. A client who is post percutaneous transluminal coronary angioplasty (PTCA) reports severe chest pain. Which action does the nurse take first? a. Administer the prescribed IV morphine. b. Administer the prescribed sublingual nitroglycerin. c. Assess the client's vital signs and notify the health care provider. d. Perform an immediate 12-lead ECG.

ANS: C After PTCA, a small percentage of clients experience acute restenosis (closure) of the affected coronary artery. Chest pain similar to that experienced before the procedure may indicate acute restenosis. The client will need to return to the catheterization laboratory to have the procedure repeated and may need stent placement to maintain a patent vessel lumen. The nurse may relieve pain with morphine or nitroglycerin after contacting the provider. The provider may request an ECG.

24. The nurse is caring for an 80-year-old client who has had coronary artery bypass graft surgery. Which assessment does the nurse prioritize for this client? a. Skin b. Otoscopic c. Mental status d. Gastrointestinal

ANS: C Assessment of mental status is important because older adults are more likely to experience transient neurologic deficits as compared with younger adults. The other assessments are not a priority for this client.

5. The emergency department nurse is assessing an 82-year-old client for a potential myocardial infarction. Which clinical manifestation does the nurse monitor for? a. Pain on inspiration b. Posterior wall chest pain c. Disorientation or confusion d. Numbness and tingling of the arm

ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations could also be related to the myocardial infarction. However, the nurse is more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

3. The community health nurse assesses clients at a health fair. Which statement assists the nurse to identify modifiable risk factors in clients with coronary artery disease? a. "Would you please state your full name and birth date?" b. "Have you ever had an exercise tolerance stress test?" c. "In what activities do you participate on a daily basis?" d. "Does anyone in your family have a history of heart disease?"

ANS: C Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (e.g., age, gender, family history). A stress test would not provide any information about risk factors.

4. The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease? a. "Rest is the best medicine at this time. Do not start an exercise program." b. "You are a man; therefore there is nothing you can do to minimize your risks." c. "You should talk to your provider about medications to help you quit smoking." d. "Decreasing the carbohydrates in your diet will help you lose weight."

ANS: C Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (e.g., age, gender, family history). The nurse needs to encourage the client to stop smoking because this is a proven risk factor for coronary artery disease development. The nurse should also encourage weight loss and moderate exercise.

6. Eight hours after presentation to the emergency department with reports of substernal chest pain, a client's laboratory results demonstrate myoglobin levels of 55 ng/mL. What does the nurse do next? a. Prepare the client for an emergency coronary bypass graft surgery. b. Administer nitroglycerin to prevent further myocardial cell death. c. Assess the client to identify another potential cause of the chest pain. d. Provide client education related to complications of myocardial infarctions.

ANS: C Myoglobin is a heme protein found in skeletal and cardiac muscle. With myocardial injury, myoglobin levels rise within 3 to 6 hours. If myoglobin levels have not risen within that time, the client has not experienced a myocardial infarction. The nurse should assess the client to identify a potential cause for the chest pain, besides an MI.

11. A client who presented with an acute myocardial infarction is prescribed thrombolytic therapy. The client had a stroke 1 month ago. Which action does the nurse take? a. Administer the medication as prescribed. b. Perform a CT scan before administering the medication. c. Contact the health care provider to discontinue the prescribed therapy. d. Administer the therapy with a normal saline bolus.

ANS: C Recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should not give the medication under any conditions. The provider must be notified and made aware of the client's stroke history. None of the other options are appropriate.

25. The nurse is planning discharge education for a client after coronary artery bypass graft surgery. Which instruction does the nurse include in this client's teaching? a. "Remember to drink at least 3 liters of fluid daily." b. "You should abstain from sexual activity for 6 months." c. "Take your pulse before, midway through, and after exercising." d. "Stop taking your antihyperlipidemic medication at this time."

ANS: C The client is instructed to begin a walking program that gradually lengthens in distance. The client is advised to take his or her pulse before exercising, midway through exercising, and after exercising. The client should stop exercising if the target rate is exceeded or if angina develops. The client should not take in large quantities of fluids or stop taking antihyperlipidemic medications. The client does not need to abstain from sexual activity.

15. The nurse is assessing a client who has left ventricular failure secondary to a myocardial infarction. Which clinical manifestation of poor organ perfusion does the nurse monitor for in this client? a. Headache b. Hypertension c. Urine output of less than 30 mL/hr d. Heart rate of 55 to 60 beats/min

ANS: C The nurse should remain alert for signs of poor organ perfusion that are the result of decreased cardiac output. When the kidneys are not well perfused, urine output drops to less than 30 mL/hr. Other signs include changes in mental status; cool, clammy extremities with decreased or absent pulses; fatigue; and recurrent chest pain. The other manifestations do not indicate poor organ perfusion.

20. The nurse is assessing a client who had percutaneous transluminal coronary angioplasty (PTCA) 1 hour ago. Which complication does the nurse monitor for? a. Hypertensive crisis b. Hyperkalemia c. Infection d. Bleeding

ANS: D In the first few postprocedure hours, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The other problems are not complications in the immediate post-PTCA period.

13. The nurse is assessing a client who has been prescribed a nonselective beta-blocking agent. Which adverse effect does the nurse monitor for in this client? a. Headache b. Postural hypotension c. Nonproductive cough d. Wheezing

ANS: D Nonselective beta blockers can cause bronchoconstriction and impair respiratory effort. Clients with pre-existing pulmonary problems should not take nonselective beta-blocking agents. Clients who develop bronchoconstriction should have their therapy changed. The other manifestations are not adverse effects of this medication.

10. The nurse assesses a client who has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestation indicates to the nurse that reperfusion has been successful? a. ST-segment depression b. Cessation of diaphoresis c. Sudden onset of pleuritic chest pain d. Onset of ventricular dysrhythmias

ANS: D The nurse monitors for the following indications of clot lysis and artery reperfusion: cessation of chest pain, sudden onset of ventricular dysrhythmias, resolution of ST-segment depression, and a peak of markers of myocardial damage at 12 hours. Pleuritic chest pain would not occur. ST-segment depression should not occur owing to reperfusion. The client may become less diaphoretic as he or she stabilizes, but this is not a classic sign of reperfusion.

9. The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not gotten any better." What does the nurse do next? a. Place the client in a semi-Fowler's position. b. Administer intravenous nitroglycerin. c. Begin supplemental oxygen at 2 L/min. d. Notify the health care provider.

ANS: D When a client experiences chest discomfort unrelieved by nitroglycerin, the client may be experiencing a myocardial infarction. The provider should be notified and the client prepared for transfer to a unit prepared to provide specialized cardiac care.