Chapter 40: Care of Patients with Acute Coronary Syndromes

The nurse is caring for a client 36 hours post coronary artery bypass grafting (CABG), with a diagnosis of activity intolerance related to imbalance of myocardial oxygen supply and demand. Which of these findings causes the nurse to terminate an activity and return the client to bed? a. Pulse 60 and regular b. Urinary frequency c. Incisional discomfort d. Respiratory rate 28

Respiratory rate 28 Tachypnea and tachycardia reflect activity intolerance; activity should be terminated.

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

Wheezing 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.

The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client should the nurse see first? a. Client with dyspnea on exertion when ambulating to the bathroom b. Client with third-degree heart block on the monitor c. Client with normal sinus rhythm and PR interval of 0.28 second d. Client who refuses to take heparin or nitroglycerin

Client with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system is involved. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. Uncooperative behavior may indicate fear or denial; he should be seen after emergency situations have been handled.

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.

Contact the health care provider to discontinue the prescribed therapy. 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.

The nurse is concerned that the client who had myocardial infarction (MI) has developed cardiogenic shock. Which of these findings indicates shock? Select all that apply. a. Bradycardia b. Cool, diaphoretic skin c. Crackles in the lung fields d. Respiratory rate of 12 e. Anxiety and restlessness f. Temperature of 100.4

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness The client with shock has cool, moist skin. Owing to extensive tissue necrosis (MI), the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Owing to poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia. Owing to pulmonary congestion, the client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.

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

Decreased cardiac output Decreased MAP Increased afterload 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.

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."

"Change position slowly." 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.

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."

"Take your pulse before, midway through, and after exercising." 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.

The older adult client, 4 hours post coronary artery bypass graft (CABG), has a blood pressure of 80/50. What action should the nurse take? a. No action is required; low blood pressure is normal for older adults. b. No action is required for postsurgical CABG clients. c. Assess pulmonary artery wedge pressure (PAWP). d. Give ordered loop diuretics.

Assess pulmonary artery wedge pressure (PAWP). Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation. Hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative clients. Further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia. Giving loop diuretics increases hypovolemia.

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? a. Reduce abdominal fat. b. Avoid stress. c. Do not smoke or chew tobacco. d. Avoid alcoholic beverages.

Do not smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causes vasoconstriction and endothelial dysfunction and thickening of the vessel wall, increases carbon monoxide, and decreases oxygen. Because this is highly addicting, beginning smoking in the teen years may lead to decades of exposure.

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.

Document the finding. 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.

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? a. 1 inch backup of blood in the IV tubing b. Facial drooping c. Partial thromboplastin time (PTT) 68 seconds d. Report of chest pressure during dye injection

Facial drooping During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding. Option A: This may be related to IV positioning. Option C: If heparin is used, this reflects a therapeutic value. Option D: Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.

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

Onset of ventricular dysrhythmias 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.

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.

The client had a myocardial infarction in the past. 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.

After receiving change-of-shift report in the coronary care unit, which client should you assess first? a. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea b. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled c. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 d. A client who has first-degree heart block, rate 68, after having an inferior myocardial infarction

The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; the client needs prompt intervention.

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

Troponin markers 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.

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

Urine output of less than 30 mL/hr 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.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? a. "You are right. Work on your diet then." b. "You must find someplace to walk." c. "Walk around the edge of your apartment complex." d. "Where might you be able to walk?"

"Where might you be able to walk?" This response calls for cooperation and participation from the client.

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.

Administer oxygen. 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.

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? a. Inferior wall b. Anterior wall c. Lateral wall d. Posterior wall

Anterior wall Owing to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure. Option A: This client is more likely to develop right ventricular MI. Option C: Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias. Option D: Clients with obstruction of the circumflex artery may experience a posterior wall MI and sinus dysrhythmias.

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

Disorientation or confusion 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.

Which of the following atypical symptoms may be present in the female client experiencing myocardial infarction (MI)? Select all that apply. a. Sharp, inspiratory chest pain b. Dyspnea c. Dizziness d. Extreme fatigue e. Anorexia

Dyspnea Dizziness Extreme fatigue Many women present with fatigue, dyspnea, and light-headedness. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

The nurse is teaching the client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. a. Truncal obesity b. Hypercholesterolemia c. Elevated homocysteine levels d. Glucose intolerance e. Client taking losartan (Cozaar)

Hypercholesterolemia Glucose intolerance Client taking losartan (Cozaar) Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol [LDL-C]), HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women, or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 or taking antihypertensive medication indicates metabolic syndrome. A large waist size (excessive abdominal fat causing central obesity)-40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women-is a sign of metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, this is not part of the metabolic syndrome.

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.

Notify the health care provider. 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.

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?"

"Do you have pain when you are resting?" 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.

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."

"I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain." 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.

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?"

"In what activities do you participate on a daily basis?" 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.

The client undergoing coronary artery bypass grafting (CABG) asks why the doctor has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? a. "This way you will not need to have a leg incision." b. "The surgeon prefers this approach because it is easier." c. "These arteries remain open longer." d. "The surgeon has chosen this approach because of your age."

"These arteries remain open longer." Mammary arteries have remained patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the prime concern. Age is not a determining factor in selection of these grafts.

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."

"You should talk to your provider about medications to help you quit smoking." 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.

An LPN/LVN is scheduled to work on the inpatient "step-down" cardiac unit where you are the team leader. Which of these clients would be best to assign to the LPN/LVN? a. A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain b. A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C c. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today d. A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia

A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today The LPN/LVN scope of practice includes administration of medications to stable clients.

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.

Administer prescribed heparin. 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.

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.

Assess the client to identify another potential cause of the chest pain. 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.

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.

Assess the client's vital signs and notify the health care provider. 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.

When caring for a client with acute myocardial infarction, the nurse recognizes that prompt pain management is essential for which reason? a. The discomfort will increase client anxiety and reduce coping. b. Pain relief improves the oxygen supply and decreases oxygen demand. c. Relief of pain indicates that the myocardial infarction is resolving. d. Pain medication should not be used until a definitive diagnosis has been established.

B: The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. The major purpose of pain relief is to reduce myocardial oxygen demand. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although this used to be true for undiagnosed abdominal pain, it does not relate to MI.

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

Bleeding 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.

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

Bleeding 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.

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.

Check for kinks in the tubing. 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.

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

Chest discomfort when mowing the lawn and subsiding with rest 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.

The client has just returned from coronary artery bypass graft (CABG) surgery. For which finding should the nurse contact the surgeon? a. Temperature 98.2° F b. Chest tube drainage 175 mL last hour c. Serum potassium 3.9 mEq/L d. Incisional pain 6 on a scale of 1 to 10

Chest tube drainage 175 mL last hour Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL per hour to the surgeon. Although hypothermia is a common problem after surgery, this is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Pain is expected immediately after major surgery; the nurse should administer prescribed analgesics.

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

Cigarette smoking Hypertension Obesity Teach about lifestyle risk factors of CAD, such as obesity, smoking, positive family history, cholesterol management, and diagnosis and treatment of hypertension.

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? a. Urine output of 1500 mL on the preceding day b. Crackles in the lung fields c. Pedal edema d. Expectoration of yellow sputum

Crackles in the lung fields Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells (WBCs) and possible infection.

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

Increased heart rate Increased contractility 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.

The nurse is providing a cardiac class for a women's group. The nurse emphasizes that which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. a. Premenopausal b. Increasing age c. Family history d. Abdominal obesity e. Breast cancer

Increasing age Family history Abdominal obesity Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size/abdominal obesity is a risk factor for both metabolic syndrome and MI. Postmenopausal women are at higher risk for MI. Breast cancer is not a risk factor for myocardial infarction.

The client comes to the emergency department with chest discomfort. Which action does the nurse perform first? a. Administers oxygen therapy b. Obtains the client's description of the chest discomfort c. Provides pain relief medication d. Remains calm and stays with the client

Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained before further action can be taken.

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

Mental status 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.

Which statement by the client scheduled for a percutaneous transluminal coronary angioplasty indicates a need for further preoperative teaching? a. "I will be awake during this procedure." b. "I will have a balloon in my artery to widen it." c. "I must lie still after the procedure." d. Obtains the client's description of the chest discomfort

Obtains the client's description of the chest discomfort Reocclusion is possible after the procedure. The client is typically awake, but drowsy, during this procedure. The client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.

The visiting nurse is seeing a client post coronary artery bypass graft. Which nursing action should be performed first? a. Assess coping skills. b. Assess for postoperative pain at the client's incision site. c. Monitor for dysrhythmias. d. Monitor mental status.

Monitor for dysrhythmias. Dysrhythmias are the leading cause of prehospital death. The nurse should monitor the client's heart rhythm.

When planning care for a client in the emergency department, the nurse recognizes that which interventions are needed in the acute phase? Select all that apply. a. Morphine sulfate b. Oxygen c. Nitroglycerin d. Naloxone e. Acetaminophen f. Verapamil (Calan, Isoptin)

Morphine sulfate Oxygen Nitroglycerin Morphine is needed to reduce oxygen demand, preload, pain, and anxiety. Administering oxygen will increase available oxygen for the ischemic myocardium. Nitroglycerin is used to reduce preload and chest pain. Naloxone is a narcotic antagonist that is used for overdosage of opiates. The client is given aspirin to chew; acetaminophen may be used for headache related to nitroglycerin. Owing to negative inotropic action, calcium channel blockers are used for angina, not for myocardial infarction (MI).

To validate that the client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? a. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase b. Homocysteine and C-reactive protein c. Total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterols d. Myoglobin and troponin

Myoglobin and troponin Myoglobin, troponin, and CK-MB are the cardiac markers used to determine whether MI has occurred. Although CK-MB is a cardiac marker, alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

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

Onset of chest pain 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.

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity should the nurse suggest? a. The need to increase activities slowly at home b. Planning and participating in a walking program c. Placing a chair in the shower for independent hygiene d. Consultation with social worker for disability planning

Placing a chair in the shower for independent hygiene Phase 1 begins with the acute illness and ends with discharge from the hospital. It focuses on promoting rest and allowing clients to improve their ADLs based on their abilities. Phase 2 begins after discharge and continues through convalescence at home. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning.

The nurse is assessing the client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? a. Chest pain brought on by exertion or stress b. Substernal chest discomfort occurring at rest c. Substernal chest discomfort relieved by nitroglycerin or rest d. Substernal chest pressure relieved only by opioids

Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Chest pain brought on by exertion or stress is indicative of angina. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Substernal chest discomfort relieved by nitroglycerin or rest is indicative of angina.

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

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

The client with unstable angina has received education about the acute coronary syndrome. Which of the following indicates that he understood the teaching? a. "This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year." b. "Angina is just a temporary interruption of blood flow to my heart." c. "I need to tell my wife I've had a heart attack." d. "Because this was temporary, I will not need to take any medications for my heart."

This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year. Among people who have unstable angina, 10% to 30% have a myocardial infarction (MI) within 1 year. Although angina pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin (ASA), lipid-lowering agents, antianginals, or antihypertensives.