Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome

Which action will the nurse take to evaluate the effectiveness of I.V nitroglycerin for a patient with a myocardial infarction (MI)?

b. Ask about chest pain. (The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand.)

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider?

b. Bilateral crackles (Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction.)

1 The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session?

b. Elevated low-density lipoprotein (LDL) level (Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. DECREASES in LDL will help reduce the patient's risk for developing CAD.)

Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider?

b. Pallor and weakness of the right hand (The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions, such as prescribed calcium channel blockers or surgery)

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?

D. "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart (The emergency response system [ERS] should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing [such as, before intercourse].)

The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization. What task should the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

b. Give the scheduled aspirin and lipid-lowering medication. (Administration of oral medications is within the scope of practice for LPNs/VNs. The initial assessment of the patient, patient teaching, and titration of I.V anticoagulant medications MUST be done by the registered nurse)

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?

b. Heart rate increases from 66 to 98 beats/min. (A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest.)

To improve the physical activity level for a mildly obese 68-year-old patient, which action should the nurse plan to take?

b. Determine what kind of physical activities the patient usually enjoys. (Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.)

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?

a. "I will sit down before I put the nitroglycerin under my tongue." (The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin.)

After having a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make?

a. "What do you think caused your chest pain?" (When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI.)

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first?

a. Attach the heart monitor. (Because dysrhythmias are the most common complication of myocardial infarction, the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.)

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider?

a. Generalized muscle aches and pains (Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.)

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

a. Reinforcement of teaching about the prescribed medications (LPN/VN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice.)

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care?

a. Tadalafil (Cialas) (The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using tadalafil because of the risk of severe hypotension caused by vasodilation.)

The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Which patient statement indicates that additional teaching is needed?

b. "I will have incisions in my leg where they will remove the vein." (When the internal mammary artery is used, there is no need to have a saphenous vein removed from the leg)

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective?

b. "It is important not to suddenly stop taking the carvedilol." (Patients who have been taking b-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol decreases myocardial contractility. Shortness of breath that occurs when taking b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, NOT by increasing blood flow to the coronary arteries.)

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best?

b. "Sexual activity uses about as much energy as climbing two flights of stairs." (Sexual activity places about as much physical stress on the cardiovascular system as moderate-energy activities, such as climbing two flights of stairs.)

The nurse is caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI). What should the nurse anticipate teaching the patient?

b. Additional diagnostic testing will be required. (Diagnostic testing [such as, stress test, Holter monitor, electrophysiologic studies, cardiac catheterization] is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will NOT have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.)

Which patient at the cardiovascular clinic requires the most immediate action by the nurse?

b. Patient with stable angina whose chest pain has recently increased in frequency. (The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are more stable.)

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?

b. The pain has lasted longer than 30 minutes. (Chest pain that lasts for 20 minutes or more is characteristic of AMI.)

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. What should teaching for this patient include today?

b. When cardiac rehabilitation will begin (Early after an AMI, the patient will want to know when resumption of usual activities can be expected)

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient?

c. "Heparin prevents the development of new clots in the coronary arteries." (Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis.)

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whetherthe patient is a candidate for thrombolytic therapy?

c. "What time did your pain begin?" (Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment.)

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow up on this symptom?

c. Auscultate for a pericardial friction rub. (The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI.)

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?

c. Bilateral crackles in the mid-lower lobes. (The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction)

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol (Lopressor)?

c. Blood pressure is 90/54 mm Hg. (Patients taking b-adrenergic blockers should be monitored for hypotension and bradycardia.)

The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion?

c. Decreased level of consciousness (The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy.)

Diltiazem (Cardizem) is prescribed for a patient with newly diagnosed Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan?

c. Decreases coronary artery spasms. (Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers [such as, diltiazem, amlodipine [Norvasc] are a first-line therapy for this type of angina.)

1. The nurse reviews information shown in the accompanying figure from the medical records of a 43-year-old patient. Which risk factor modification for coronary artery disease should the nurse include in patient teaching?

c. Dietary changes to improve lipid levels (The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. The patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.)

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one should the nurse arrange to be completed first?

c. Electrocardiogram (ECG) (The priority for the patient is to determine whether an acute myocardial infarction [AMI] is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG.)

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication?

c. Give the patient's other medications 2 hours after colesevelam. (The bile acid sequestrants INTERFERES with the absorption of many other drugs and giving other medications at the same time should be avoided.)

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes?

c. Help the patient modify favorite high-fat recipes by using monounsaturated oils. (Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats.)

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?

c. No change in the patient's reported level of chest pain (Continued chest pain suggests that the thrombolytic therapy is NOT effective and that other interventions such as percutaneous coronary intervention may be needed.)

A patient with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

c. Pedal pulses 1+ bilaterally (The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.)

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. What should the nurse teach the patient about the primary purpose of captopril?

c. Prevents changes in heart muscle. (The purpose for angiotensin-converting enzyme [ACE] inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to DECREASE ventricular remodeling)

Which electrocardiographic (ECG) change by a patient with chest pain is most important for the nurse to report rapidly to the health care provider?

c. ST-segment elevation (The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention [PCI] or thrombolytic medication is indicated to minimize myocardial damage.)

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?

d. "I will miss being able to eat peanut butter sandwiches." (Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet.)

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina?

d. "The pain goes away after a nitroglycerin tablet." (Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.)

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first?

d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI). (After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.)

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction [AMI]. Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?

d. Cardiac-specific troponin (Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction [MI] and are highly specific indicators for MI.)

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority?

d. Decreased cardiac output (The hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs [such as, brain, kidney, heart] and is a priority)

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective?

d. Participation in daily activities without chest pain (Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain.)