Chapter 27: Management of Patients With Coronary Vascular Disorders

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? creatine kinase myoglobin lactate dehydrogenase troponin

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 the studies are less specific indicators of myocardial damage than troponin.

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. Take over-the-counter decongestants. Avoid fatty foods and exercise. Report changes in the usual pattern of chest pain.

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.

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? Withhold anticoagulant therapy. Assess distal pulses. Inform client of diagnostic tests. Remove hair from skin insertion sites.

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.

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 cerebral bleeding I.M. injection skeletal muscle damage due to a recent fall

myocardial necrosis 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.

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin? Amlodipine Clopidogrel Diltiazem Felodipine

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.

The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse? bilateral rales and rhonchi serum glucose of 124 mg/dL weight gain of 6 ounces potassium level of 6 mEq/L

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 is not significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed.

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 resolved after I ate a sandwich." "The pain lasted about 45 minutes." "The pain occurred while I was mowing the lawn." "The pain got worse when I took a deep breath."

"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.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding? "Is your skin drier than normal?" "What color is your urine?" "How is your appetite?" "Do you have any breathing problems?"

"What color is your urine?" 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.

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication? 280-300 mg/dL 160-190 mg/dL 250-275 mg/dL 210-240 mg/dL

160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

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. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs.

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.

You are caring for a client with CAD. What is an appropriate nursing action when evaluating a client with coronary artery disease (CAD)? Assess the client's mental and emotional status. Assess for any kind of drug abuse. Assess the skin of the client. Assess the characteristics of chest pain.

Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental, emotional status, the skin of the client, or for drug abuse will not assist the nurse in evaluating the client for CAD.

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 Cool, clammy skin and a diaphoretic, pale appearance Intermittent nausea and emesis for 3 days Anxiousness, restlessness, and lightheadedness

Chest discomfort not relieved by rest or nitroglycerin 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.

The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration? Measure the blood pressure for hypertension. Count the respiratory rate for bradypnea. Measure urinary output for dehydration. Check the radial pulse for dysrhythmias.

Count the respiratory rate for bradypnea. The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.

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? Creates a positive inotropic effect Increases the heart rate Decreases the sinoatrial node automaticity Increases the atrioventricular node conduction

Decreases the sinoatrial node automaticity 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 presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display? Cholesterol plugs in the lumen of veins Fatty deposits in the lumen of arteries Emboli in the veins Blood clots in the arteries

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 nurse is caring for a client after cardiac surgery. Upon assessment, the client appears restless and reports nausea and weakness. The client's ECG reveals peaked T waves. The nurse reviews the client's serum electrolytes, anticipating which abnormality? Hypomagnesemia Hyponatremia Hyperkalemia Hypercalcemia

Hyperkalemia 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 changes in T-wave formation.

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? Overhydration Anuria Normal glomerular filtration Inadequate fluid volume

Inadequate fluid volume 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.

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? Potassium Sodium Magnesium Calcium

Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

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 exhibits a heart rate above 100 beats/minute. The client demonstrates ability to tolerate more activity without chest pain. The client states that sublingual nitroglycerin usually relieves his chest pain. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking.

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.

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. The patient has an ejection fraction of 65%. The patient has had angina longer than 3 years. The patient has compromised left ventricular function.

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).

A patient with angina is beginning nitroglycerin. Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what? Throbbing headache or dizziness Tinnitus or diplopia Nervousness or paresthesia Drowsiness or blurred vision

Throbbing headache or dizziness Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the patient usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.

Which term refers to preinfarction angina? Stable angina Variant angina Unstable angina Silent ischemia

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.

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 Within 12 hours Within 5 to 7 days Within 24 to 48 hours

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.

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 a urine specific gravity reading of 1.021 an hourly urine output of 50 to 70 mL a serum creatinine of 1.0 mg/dL

a serum BUN of 70 mg/dL 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.

A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? heart rate of 87 bpm hematocrit of 30% hemoglobin of 16 g/dL blood pressure of 129/72 mm Hg

hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse? Minimal oozing of blood from the IV site Presence of reperfusion dysrhythmias Altered level of consciousness Chest pain 2 of 10 (on a 1-to-10 pain scale)

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.

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? Educate the family about how confusion is expected in older adults postoperatively. Assess for factors that may be causing the client's delirium. Reorient the client to place and time. Document the early signs of dementia and ensure the client's safety.

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 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 Protamine sulfate Digoxin Sodium nitroprusside

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.

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 you suspect in this client? Cardiogenic shock Raynaud's disease Coronary artery disease Venous occlusive disease

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 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? Increases cardiac output Decreases cholesterol level Decreases resting heart rate Decreases platelet aggregation

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 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 nitroglycerin Amlodipine Atenolol

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.

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 prevent angiotensin II conversion To decrease homocysteine levels To decrease workload of the heart To dilate coronary arteries

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

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 Chest pain is typical Gender bias Decreased sensation to pain

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 client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? beta-adrenergic blocker diuretic calcium-channel blocker nitrate

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.

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply. Initiate passive exercises. Place pillows in the popliteal space. Apply antiembolism stockings. Encourage the client to cross their legs. Avoid elevating the knees on the bed.

Apply antiembolism stockings. Avoid elevating the knees on the bed. Initiate passive exercises. Preventive measures used to prevent venous stasis include application of sequential pneumatic compression devices; discouraging crossing of legs; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; and beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? Elevated blood glucose level Urinary tract infection (UTI) Atelectasis Hyperkalemia

Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

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? Ativan 1 mg orally Nitroglycerin SL Chest x-ray Serum electrolytes

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.

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? Frequent premature atrial contractions (PACs) Sinus tachycardia ST elevation Isolated premature ventricular contractions (PVCs)

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.

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Rectal bleeding Hematemesis Hypertensive crisis Severe back pain

Severe back pain Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe back pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.

The nurse is caring for a client diagnosed with coronary artery disease (CAD). What condition most commonly results in CAD? atherosclerosis diabetes mellitus myocardial infarction renal failure

atherosclerosis 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

The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome? hypothermia decreased erythrocyte sedimentation rate (ESR) decreased white blood cell (WBC) count pericardial friction rub

pericardial friction rub Post-pericardiotomy 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. Hypothermia is not a symptom of post-pericardiotomy syndrome.

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 normal. low. extremely high. high.

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 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? Aspirin Alteplase Clopidogrel Protamine sulfate

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.

A client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6 °F (37.6 °C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. What assessment is the nurse's highest priority? body temperature acute pain anxiety cardiac output

acute pain The assessment of pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis. The client's blood pressure and heart rate do not suggest a decreased cardiac output. Anxiety may be an important assessment, but addressing acute pain (the priority concern) may alleviate the client's anxiety.

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? penicillin V or erythromycin. aspirin or acetaminophen. aspirin or clopidogrel. pentoxifylline or acetaminophen.

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.