Med-Surge Nursing Cardio Prep U ch 27

A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease?

Assess chest pain and administer prescribed drugs and oxygen The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin?

Clopidogrel Clopidogrel or ticlopidine is given to clients who are allergic to aspirin or are given in addition to aspirin to clients who are at high risk for MI. Amlodipine, diltiazem, and felodipine are calcium channel blockers.

A patient is given a prescription for Lopressor, a beta-blocker, after being examined by his health care provider. Select the most important information the nurse should provide.

Don't suddenly stop taking the medication without calling your health care provider. All teaching points need to be covered, but the nurse needs to emphasize that Lopressor should not be suddenly stopped because some conditions can become worse.

A patient's elevated cholesterol levels are being managed with Lipitor, 40 mg daily. The nurse practitioner reviews the patient's blood work every 6 months before renewing the prescription. The nurse explains to the patient's daughter that this is necessary because of a major side effect of Lipitor that she is checking for. What is that side-effect?

Increased liver enzymes Myopathy and increased liver enzymes are significant side effects of the statins, HMG-CoA reductase inhibitors that are used to affect lipoprotein metabolism.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

Which s the analgesic of choice for acute myocardial infarction (MI)?

Morphine The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety. Aspirin is an antiplatelet medication. Meperidine and Ibuprofen are not the analgesics of choice.

A client was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?

Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn't be performed during an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)?

The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?

To decrease workload of the heart Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and Bvitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?

Unstable Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Which term refers to preinfarction angina?

Unstable angina Preinfarction angina is also known as unstable angina. Stable angina has predictable and consistent pain that occurs upon exertion and is relieved by rest. Variant angina is exhibited by pain at rest and reversible ST-segment elevation. Silent angina manifests through evidence of ischemia, but the client reports no symptoms.

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?

Vague symptoms Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.

A patient, who is resting quietly in a step-down cardiac care unit, reports chest pain. The cardiac monitor indicates the presence of reversible ST-segment elevation. The nurse understands that the patient may be experiencing coronary artery vasospasm. This is a type of angina known as:

Variant Variant or Prinzmetal's angina is distinguished by its occurrence during rest, as opposed to stable angina, which occurs with activity. Silent angina occurs without symptoms, and intractable angina is evidenced by incapacitating pain.

An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician orders a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for:

a history of diabetes mellitus Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren't a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn't been identified as a major risk factor for CAD.

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug?

calcium-channel blocker Calcium-channel blocking agents may be used to treat CAD as well, although research has shown that they may be less beneficial than beta-adrenergic blocking agents. Diltiazem (Cardizem) is an example of a calcium-channel blocker.

A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many milliliters per hour will the nurse infuse this solution? Record your answer using a whole number.

24 (1200 units/25,000 units) X 500 mL = 24 mL.

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include?

"Client will verbalize the intention to stop smoking." A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).

A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?

"Exercise, keep your blood sugar in check, and manage your stress." Although moderation is the key, this does not provide specific options for this client such as regular exercise and managing stress and cholesterol levels. The reverse lipid drug sounds good but is not available or approved by the FDA. Soy products have limited benefits for cholesterol control.

The nurse has completed a teaching session on self-administration of sublingual nitroglycerin. Which client statement indicates that the teaching has been effective?

"I can take nitroglycerin before sex so I won't develop chest pain". Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e., before an angina-producing activity such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart; if the chest pain is not relieved, emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., a capped dark glass bottle), and tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin include flushing, throbbing headache, hypotension, and tachycardia.

A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?

"I should expect a low-grade fever and swelling at the site for the next week." Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?

"Removing the patch at night prevents drug tolerance while keeping the benefits." Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while the client rests, there is less demand on the heart but not the primary reason for removing the patch.

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions?

"See if rest relieves the chest pain before using the nitroglycerin." Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. The client should expect to feel dizzy or flushed or to develop a headache following sublingual nitroglycerin use. The client should place one nitroglycerin tablet under the tongue if 2-3 minutes of rest fails to relieve pain. Clients may take up to three nitroglycerin tablets within 5 minutes of each other to relieve angina. However, they should call 911 if the three tablets fail to resolve the chest pain.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

"Tell me what concerns you most." Allowing the client to share feelings tends to relieve or reduce emotional distress. Telling a client that everything is fine negates the feelings they are expressing. Telling a client not to cry can be viewed as insensitive to the feelings being expressed. Providing a prescribed sedative may be helpful but does not address the fears and concerns of the client.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?

"The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

The nurse is caring for a client experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase. Before administering this medication, which question is most important for the nurse to ask the client?

"What time did your chest pain start today?" The client may be a candidate for thrombolytic (fibrolytic) therapy. These medications are administered if the client's chest pain lasts longer than 20 minutes and is unrelieved by nitroglycerin, if ST-segment elevation is found in at least two leads that face the same area of the heart, and if it has been less than 6 hours since the onset of pain. The most appropriate question for the nurse to ask is in relations to when the chest pain began. The other questions would not aid in determining whether the client is a candidate for thrombolytic therapy.

The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply.

1. Balance rest with activity. 2. Stop smoking. 3. Carry nitroglycerin at all times. Managing angina pectoris at home includes balancing rest with activity, participating in a regular daily program of activities that do not induce angina pain, stopping smoking, carrying nitroglycerin at all times, and following a diet low in saturated fat.

The nurse is providing education about the nutrient content of the Therapeutic Lifestyle Changes (TLC) diet to a community group. What information will the nurse provide? Select all that apply.

1. Carbohydrates should make up 50% to 60% of the total calories. 2. Dietary fiber should be 20 to 30 grams per day. 3. Protein should make up approximately 15% of total calories. According to the nutrient content of the TLC diet, cholesterol should make up less than 200 mg/day, carbohydrates should make up 50% to 60% of the total calories, dietary fiber should be 20 to 30 grams per day, protein should make approximately 15% of the total calories, and fat should make up 25% to 30% of the total calories.

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.)

1. It is substernal in location. 2. It is sudden in onset and prolonged in duration. 3. It is viselike and radiates to the shoulders and arms. Chest pain that occurs suddenly, continues despite rest and medication, is substernal, and is sometimes viselike and radiating to the shoulders and arms is associated with an MI. Angina pectoris pain is generally relieved by rest and nitroglycerin.

Heparin therapy is usually considered therapeutic when the client's activated partial thromboplastin time (aPTT) is how many times normal?

2.0 to 2.5 The amount of heparin administered is based on aPTT results, which should be obtained during the follow-up to any alteration of dosage. The client's aPTT value would have to be greater than .25 to .75 or .75 to 1.5 times normal to be considered therapeutic. An aPTT value that is 2.5 to 3 times normal would be too high to be considered therapeutic.

A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse?

3 minutes Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally alleviates the pain of ischemia within 3 minutes.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. With regards to partial thromboplastin time (PTT), when should the nurse plan to remove the femoral sheath?

50 seconds or less. Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)?

60 minutes The 60-minute interval is known as "door-to-balloon time" in which a PTCA can be performed on a client with a diagnosed MI. The 30-minute interval is known as "door-to-needle time" for the administration of thrombolytics after MI. The time frame of 9 days refers to the time until the onset of vasculitis after administration of streptokinase for thrombolysis in a client with an acute MI. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same client for acute MI.

The nurse has been asked to explain the cause of angina pain to a patient's family. Choose the best statement. The pain is due to:

A lack of oxygen in the heart muscle that causes the death of cells. Impeded blood flow, due to blockage in a coronary artery, deprives the cardiac muscle cells of oxygen thus leading to a condition known as ischemia.

The charge nurse was discussing with the nursing student that studies have been published that suggest inflammation increases the risk of heart disease. Which modifiable factor would the nursing student target in teaching clients about prevention of inflammation that can lead to atherosclerosis?

Addressing obesity Published information by Balistreri et al. (2010) indicated a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests decreasing obesity and body fat stores may help to reduce the risk. Avoid- ing the use of caffeine, encouraging the use of a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to artherosclerosis.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse?

Altered level of consciousness A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client's chest pain is subsiding, an expected outcome of this therapy.

Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is most effective?

Application of a vascular closure device such as Angio-Seal or VasoSeal Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site and application of a pneumatic compression device after PTCA have been demonstrated to be effective; the former was the first method used to induce hemostasis after PTCA. Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding.

After percutaneous transluminal coronary angioplasty (PTCA), the nurse suspects that a patient, who is on bed rest, may be experiencing the complication of bleeding. The nurse's initial action should be to do which of the following?

Apply manual pressure at the site of the insertion of the sheath. The immediate nursing action would be to apply pressure, which may stop the bleeding. If the bleeding does not stop, the health care provider needs to be notified.

A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response?

Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age. Arteriosclerosis refers to the loss of elasticity or hardening of the arteries, that accompanies the aging process. Therefore, options B, C, and D are incorrect.

An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take?

Assess for factors that may be causing the client's delirium. Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.

The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol?

Atropine Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.

The nurse is caring for a client with Raynaud's disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants

Aortic stenosis remains asymptomatic for several decades. However, once a client becomes symptomatic for aortic stenosis, life expectancy without further treatment is only 2 to 3 years. What is the treatment of choice for symptomatic aortic stenosis?

Balloon valvuloplasty Additional treatment eventually becomes critical because average survival is 2 to 3 years once symptoms develop. Balloon valvuloplasty is an invasive, nonsurgical procedure to enlarge a narrowed valve opening. Balloon angioplasty, cardiac catheterization, and cardiac graft procedure are not indicated treatments for aortic stenosis.

Which is a diagnostic marker for inflammation of vascular endothelium?

C-reactive protein (CRP) CRP is a marker for inflammation of the vascular endothelium. LDL, HDL, and triglycerides are not markers of vascular endothelial inflammation. They are elements of fat metabolism.

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The health care provider diagnoses acute coronary syndrome. When the client arrives on the unit, vital signs are stable and the client does not report any pain. In addition to the medications already given, which medication does the nurse expect the health care provider to order?

Carvedilol A client with suspected myocardial infarction should receive aspirin, nitroglycerin, morphine, and a beta-adrenergic blocker such as carvedilol. Digoxin treats arrhythmias; there is no indication that the client is having arrhythmias. Furosemide is used to treat signs of heart failure, which isn't indicated at this point. Nitroprusside increases blood pressure. This client has stable vital signs and isn't hypotensive.

A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse?

Central venous pressure reading of 1 The central venous pressure (CVP) reading of 1 is low (2-6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.

A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?

Coronary artery disease The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud's disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger?

Coronary artery spasm. Prinzmetal's angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; anginal pain becomes increasingly severe.

The nurse is reviewing the laboratory results for a patient having a suspected myocardial infarction (MI). What cardiac-specific isoenzyme does the nurse observe for myocardial cell damage?

Creatine kinase MB here are three creatine kinase (CK) isoenzymes: CK-MM (skeletal muscle), CK-MB (heart muscle), and CK-BB (brain tissue). CK-MB is the cardiac-specific isoenzyme; it is found mainly in cardiac cells and therefore increases when there has been damage to these cells. Elevated CK-MB is an indicator of acute MI; the level begins to increase within a few hours and peaks within 24 hours of an infarct.

The nurse is caring for a client who was admitted to the telemetry unit with a diagnosis of "rule/out acute MI." The client's chest pain began 3 hours earlier. Which laboratory test would be most helpful in confirming the diagnosis of a current MI?

Creatinine kinase-myoglobin (CK-MB) level Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (as a result of thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. Three isomers of troponin exist: C, I, and T. Troponins I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect?

Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. In general, the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display?

Fatty deposits in the lumen of arteries Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol (Lopressor), 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?

Heart Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

A nurse is monitoring the vital signs and blood results of a 53-year-old male patient who is receiving anti-coagulation therapy. Which of the following does the nurse identify as a major indication of concern?

Hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lowered hematocrit can imply internal bleeding.

The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD?

High-density lipoprotein (HDL), 80 mg/dL A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.

Which of the following is inconsistent as a condition related to metabolic syndrome?

Hypotension A diagnosis of metabolic syndrome includes three of the following conditions: insulin resistance, abdominal obesity, dyslipidemia, hypertension, proinflammatory state, and prothrombotic state.

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload?

IV morphine IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of atenolol and amlodipine are not indicated in this situation.

A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?

Improve venous return The major goal in management of venous insufficiency is to promote venous circulation. Arterial flow improvement is not the goal of treatment for this disorder. Venous valves that are incompetent cannot be strengthened. Venous congestion is a complication of venous insufficiency.

Which of the following would be inconsistent as criterion of extubation in the patient who has undergone a coronary artery bypass graft (CABG)?

Inability to speak. Before being extubated, the patient should have cough and gag reflexes and stable vital signs; be able to life the head off the bed or give firm hand grasps; have adequate vital capacity, negative inspiratory force, and minute volume appropriate for body size; and have acceptable ABG levels while breathing without the assistance of the ventilator. Inability to talk is expected when intubated with an endotracheal tube.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025), the nurse suspects:

Inadequate fluid volume Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 25 mL or greater per hour and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric patient does not produce urine.

A client has been recently placed on nitroglycerin. Which instruction by the nurse should be included in the client's teaching plan?

Instruct the client on side effects of flushing, throbbing headache, and tachycardia. The client should be instructed about side effects of the medication, which include flushing, throbbing headache, and tachycardia. The client should renew the nitroglycerin supply every 6 months. If the pain is severe, the client can crush the tablet between the teeth to hasten sublingual absorption. Tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerin is very unstable and should be carried in its original container.

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following?

Low blood pressure The patient receiving anticoagulation therapy should be monitored for signs and symptoms of external and internal bleeding, such as low blood pressure, increased heart rate, and decreased serum hemoglobin and hematocrit.

As part of health education for a patient with an abnormal fasting lipid profile, the nurse explains that an excess of this lipid leads to the formation of plaque in the arteries. Identify the lipid.

Low-density lipoproteins (LDL) When there is an excess of LDL, these particles adhere to vulnerable points in the arterial endothelium. Here, macrophages ingest then, leading to the formation of foam cells and the beginning of plaque formation. A harmful effect is exerted on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining.

Which technique is used to surgically revascularize the myocardium?

Minimally invasive direct coronary bypass Several techniques are used to surgically revascularize the myocardium; one of them is minimally invasive direct coronary bypass. Balloon bypass is not used to revascularize the myocardium. If the client is experiencing acute pain in the leg, peripheral bypass is performed. Gastric bypass is a surgical procedure that alters the process of digestion.

Upon discharge from the hospital, patients diagnosed with a myocardial infarction (MI) must be placed on all of the following medications except:

Morphine IV Upon patient discharge, there needs to be documentation that the patient was discharged on a statin, an ACE or angiotensin receptor blocking agent (ARB), and aspirin. Morphine IV is used for these patients to reduce pain and anxiety. The patient would not be discharged with IV morphine.

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?

Morphine sulfate (Morphine) Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina-type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.

A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of what medication?

Nitroglycerin A cholinergic blocking agent may cause dry mouth and delay the sublingual absorption of nitroglycerin. The nurse should offer the client sips of water before administering nitroglycerin. Amantadine, digoxin, and diphenhydramine can interact with a cholinergic blocking agent but not through delayed absorption. Amantadine and diphenhydramine enhance the effects of anticholinergic agents.

A client presents to the ED reporting anxiety and chest pain after shoveling heavy snow that morning. The client says that nitroglycerin has not been taken for months but upon experieincing this chest pain did take three nitroglycerin tablets. Although the pain has lessened, the client states, "They did not work all that well." The client shows the nurse the nitroglycerin bottle; the prescription was filled 12 months ago. The nurse anticipates which order by the physician?

Nitroglycerin SL Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired, and the nurse should anticipate administering nitroglycerin to assess whether the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the client's chest pain.

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome?

Pericardial friction rub The syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR.

The nurse, caring for a patient after cardiac surgery, is aware that fluid and electrolyte imbalance is a concern. Select the most immediate result that needs to be reported.

Potassium level of 6 mEq/L Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L. An elevated blood sugar is common postoperatively, and the weight gain isn't significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed.

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?

Protamine sulfate Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

After undergoing cardiac surgery, a client discovers a painless lump and reports this to the nurse. What is the most important nursing intervention for this client?

Reassure the client by informing him or her that the lump will disappear with time. The nurse will reassure the client by informing him or her that the lump will disappear with time and will not require surgery, drug therapy, or a visit to the health care provider.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?

ST elevation The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?

The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.

Two female nursing assistants approach a nurse on a cardiac step-down unit to report that a client who experienced an acute myocardial infarction made sexual comments to them. How should the nurse intervene?

The nurse should explain that the client might have concerns about resuming sexual activity but is afraid to ask. Sometimes clients are concerned about resuming sexual activity but are afraid to ask. Making inappropriate sexual comments provides a forum for asking questions. It isn't necessary to report the incident to the nursing supervisor immediately without investigating the situation further. The client's call light must be answered in a timely fashion. More information is needed before assuming that the client is asking for extra attention.

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?

Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Health care providers initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur?

Worsening angina Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or thrombocytopenia.

An client who has been diagnosed with arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is:

an expected part of the aging process. Arteriosclerosis is loss of elasticity or hardening of the arteries that accompanies the aging process. While arteriosclerosis is a contributing factor to vascular occlusive disease, it is a term that refers to a loss of elasticity or hardening of the arteries that accompanies the aging process. Arteriosclerosis does not involve scar tissue formation. Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. What type of MI did this client have?

anterior An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. Posterior, lateral, and inferior MI aren't usually associated with heart failure.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an:

anticoagulant During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will be prescribed long-term administration of which drug?

aspirin or clopidogrel After PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Health care providers order heparin for anticoagulation during this procedure; some health care providers discharge clients with a prescription for long-term warfarin or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn't required after PTCA because the procedure itself opens the vessel. The health care provider may order short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn't warranted. The client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn't necessary.

A client who has been diagnosed with Prinzmetal's angina will present with which symptom?

chest pain that occurs at rest and usually in the middle of the night A client with Prinzmetal's angina will complain of chest pain that occurs at rest, usually between 12 and 8:00 AM, is sporadic over 3-6 months, and diminishes over time. Clients with stable angina generally experience chest pain that lasts 15 minutes or less and may radiate. Clients with Cardiac Syndrome X experience prolonged chest pain that accompanies exercise and is not always relieved by medication. Clients with unstable angina experience chest pain of increased frequency, severity, and duration that is poorly relieved by rest or oral nitrates.

The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be to:

enhance myocardial oxygenation. Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.

A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a:

high LDL level. LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.

The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low-density lipoprotein (LDL) level is 112 mg/dL. This nurses recognizes that this value is

high. If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be high. The goal is to decrease the LDL level below 100 mg/dL.

The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as

high. The normal LDL range is 100 to 130 mg/dL. A level of 115 mg/dL is considered to be high. The goal of treatment is to decrease the LDL level below 100 mg/dL (less than 70 mg/dL for very high-risk clients).

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with

percutaneous coronary intervention (PCI) The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must determine whether the client has which absolute contraindication to thrombolytic therapy?

prior intracranial hemorrhage History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.

A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency department. In terms of serum testing, it's most important for the physician to order cardiac:

troponin This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific indicators of myocardial damage than troponin.

A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency department. In terms of serum testing, it's most important for the physician to order cardiac:

troponin. This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific indicators of myocardial damage than troponin.