Chapter 27: Management of Patients with Coronary Vascular Disorders

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?

"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention

A client with a family history of coronary artery disease reports experiencing chest pain and palpitations during and after morning jogs. What would reduce the client's cardiac risk?

smoking cessation Explanation: The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight. Antioxidant supplements, such as those containing vitamin E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use.

The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client?

troponin Explanation: 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 the studies are less specific indicators of myocardial damage than troponin

A client who is resting quietly reports chest pain to the nurse. The cardiac monitor indicates the presence of reversible ST-segment elevation. What type of angina is the client experiencing?

variant angina Explanation: Variant or Prinzmetal's angina is distinguished by pain occurrence during rest. Stable angina occurs with activity. Silent angina occurs without symptoms, and intractable angina is evidenced by incapacitating pain.

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?

"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.

A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). Which evaluation statement suggests that the client needs more instruction?

"Client walks 4 miles in 1 hour every day." Explanation: Four weeks after an MI, a client's walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises, following a low-fat, low-cholesterol diet, and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

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." Explanation: 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 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." Explanation: Tolerance to antianginal 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.

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

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." Explanation: 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.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding?

"What color is your urine?" Explanation: The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine. Anticoagulation therapy should not cause dry skin. The anticoagulation therapy should not change the client's breathing or appetite.

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

5 minutes Explanation: 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). The nurse should instruct the client to take a second dose five minutes after the first if pain persists. The nurse should instruct the client to take a third dose five minutes after the second if pain still persists. The nurse should advise the client to call 911 if pressure or pain is not releived in 15 minutes by taking 3 tablets at 5-minute intervals.

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 Explanation: 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.

After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse's initial action?

Apply manual pressure at the site of the insertion of the sheath. Explanation: The immediate nursing action would be to apply pressure to the femoral site. Reviewing blood studies will not stop the bleeding. The nurse cannot decrease anticoagulation therapy independently. If the bleeding does not stop, the health care provider needs to be notified.

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 Explanation: 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.

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. Explanation: 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 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. Explanation: 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.

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

Blood pressure 84/52 mm Hg Explanation: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

Which is a diagnostic marker for inflammation of vascular endothelium?

C-reactive protein (CRP) Explanation: 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.

Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles?

Cardiac tamponade Explanation: Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.

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 Explanation: 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 middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)?

Chest discomfort not relieved by rest or nitroglycerin Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent?

Clopidogrel Explanation: Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.

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 Explanation: 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.

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient?

Decreases the sinoatrial node automaticity Explanation: Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

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

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?

Headache, hypotension, dizziness, and flushing. Explanation: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic that relieves pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality?

Hyperkalemia Explanation: Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

Hyperlipidemia Obesity Tobacco use Explanation: Modifiable risk factors for coronary artery disease include hyperlipidemia, tobacco use, hypertension, diabetes mellitus, metabolic syndrome, obesity, and physical inactivity. Nonmodifiable risk factors include family history, advanced age, gender, and race.

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

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

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?

Hypotension Explanation: The patient is observed for any adverse effects of opioids, which may include respiratory depression, hypotension, ileus, or urinary retention. If serious side effects occur, an opioid antagonist, such as Narcan, may be used.

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 Explanation: 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.

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?

Inadequate fluid volume Explanation: Urine output less than 0.5 mL/kg/h 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 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.

Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery?

Inadequate tissue perfusion Explanation: The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for clients undergoing cardiac surgery.

The nurse notes that the post cardiac surgery client demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025). What will the nurse anticipate the health care provider will order?

Increase intravenous fluids Explanation: 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. The health care provider may increase intravenous fluids. Irrigating the urinary catheter will be done if there is a suspected blockage. Dialysis is not indicated by urinary volumes.

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

Withhold anticoagulant therapy. Explanation: 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 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. Explanation: 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.

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 experiencing 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 Explanation: 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.

While receiving a heparin infusion to treat deep vein thrombosis, a client reports bleeding in the gums when brushing teeth. What should the nurse do first?

Notify the health care provider. Explanation: Because heparin can cause bleeding gums that may indicate excessive anticoagulation, the nurse should notify the health care provider, who will evaluate the client's condition. The health care provider should order laboratory tests such as partial thromboplastin time before concluding that the client's bleeding is significant. The ordered heparin dose may be therapeutic rather than excessive, so the nurse shouldn't discontinue the heparin infusion unless the health care provider orders this after evaluating the client. Protamine sulfate, not a coumarin derivative, is given to counteract heparin. Heparin doesn't normally cause bleeding gums.

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 Explanation: 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.

Which medication is an antidote to heparin?

Protamine sulfate Explanation: Protamine sulfate is known as the antagonist to heparin. Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?

Relieved by rest and nitroglycerin Explanation: One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.

A nurse is assigned to care for a recently admitted client who has been diagnosed with refractory angina. What symptom will the nurse expect the client to exhibit?

Severe, incapacitating chest pain Explanation: Refer to Box 14-2 in the text for a detailed explanation of the difference characteristics of chest pain.

The nurse is educating the patient about administering nitroglycerin prior to discharge from the hospital. What information should the nurse include in the instructions?

Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system. Explanation: The nurse should recommend that the patient note how long it takes for the nitroglycerin to relieve the discomfort. Advise the patient that if pain persists after taking three sublingual tablets at 5-minute intervals, emergency medical services should be called

The client is prescribed nadolol for hypertension. What is the reason the nurse will teach the client not to stop taking the medication abruptly?

The abrupt stop can cause a myocardial infarction. Explanation: 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 the onset of a migraine headache.

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme?

myocardial necrosis Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse?

The nurse will ask the dietitian to talk with the client about modifying the diet. Explanation: A dietitian can help the client decrease the fat in the diet and make other beneficial dietary modifications. This client's total cholesterol isn't within the recommended guidelines; it should be less than 200 mg/dl. LDL should be less than 79 mg/dl, and HDL should be greater than 40 mg/dl. Although this client should take statin medication, the client should still be concerned about cholesterol levels and make other lifestyle changes, such as dietary changes, to help lower it. The client should increase activity level, but doesn't need to run 2 miles per day.

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 Explanation: 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 B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks?

Troponin Explanation: Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin peaks within 12 hours after the onset of symptoms. Total creatine kinase (CK) returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

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 Explanation: 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.

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 Explanation: 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 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 Explanation: 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.

The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain?

a lack of oxygen in the heart muscle cells Explanation: Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction

The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure?

a serum BUN of 70 mg/dL Explanation: These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.

The nurse is caring for a client diagnosed with coronary artery disease (CAD). What condition most commonly results in CAD?

atherosclerosis Explanation: Atherosclerosis (plaque formation) is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

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

calcium-channel blocker Explanation: 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.

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). Explanation: 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.