Coronary Artery Disease/ Coronary Heart Disease- EDEN

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6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

A Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. Cognitive Level: Analysis Text Reference: pp. 828-829 Nursing Process: Implementation NCLEX: Physiological Integrity

1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment NCLEX: Physiological Integrity

A nurse is conducting teaching about risk factor management for cardiovascular disease (CVD) at a senior center. What is the most important info for the nurse to include? 1. Stop smoking. 2. Eat in moderation. 3. Exercise when able. 4. Reduce saturated fats in the diet.

Answer: 1 Rationale 1: Cigarette smoking is the leading independent risk factor for coronary heart disease. Rationale 2,3,4: The remaining options are teaching points, but are not specific. The problems associated with the remaining options are not as significant as smoking.

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram

ANS: A Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened.

25. 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. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).

26. A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Flushing and pruritus after taking the medications

ANS: A 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.

27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Sildenafil (Viagra) b. Furosemide (Lasix) c. Captopril (Capoten) d. Warfarin (Coumadin)

ANS: A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

ANS: A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.

21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had 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?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: A 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. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

33. 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. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

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

39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

ANS: B 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.

3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

ANS: B Diagnostic testing (e.g., 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.

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

ANS: B Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

ANS: B Patients who have been taking β-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking β-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

ANS: B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc

23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

13. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

ANS: B 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 stable.

22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

ANS: B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

ANS: C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

32. 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 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

ANS: C All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

ANS: C 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 monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

35. 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? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

42. After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Ongoing cardiac risk associated with history of tobacco use

ANS: C The patient has an elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index (BMI) 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.

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.

18. 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 check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

ANS: C 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. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

17. A patient is recovering from a myocardial infarction (MI) and 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 next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

37. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion 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 (MI). Peripheral access will be needed but not before the ECG.

41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to a. lower heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.

ANS: C 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. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated 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. The other patient comments indicate a good understanding of the TLC diet.

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.

ANS: D 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.

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

ANS: D Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective β-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice.

43. 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? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

ANS: D Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? a. Have the patient take this medication with an aspirin. b. Administer the medication at the patient's usual bedtime. c. Have the patient take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.

ANS: D The bile acid sequestrants interfere with the absorption of many other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

ANS: D 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.

38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

ANS: D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, 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.

8. 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 should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

During a follow-up appointment after a myocardial infarction, a pt states, "My friends tell me to add more garlic to my diet & start drinking red wine each evening." Which response by the nurse is best? 1. "Discuss your idea with the physician to see what would benefit you." 2. "That sounds fine. See how they work." 3. "I wouldn't do that if I were you." 4. "You should also add ginkgo biloba for cardiovascular health."

Answer: 1 Rationale 1: Complimentary therapies could be helpful. They should be added only after discussion with a healthcare provider who is familiar with the pt's history & current med/allergy list. Interactions between herbal preparations & prescribed meds are common. Rationale 2: They should be added only after discussion with a healthcare provider who is familiar with the pt's history & current medication/allergy list. Rationale 3: Since the pt has taken an interest in her health by discussing it with her friends, ignoring her comment or discouraging her would not be beneficial. Rationale 4: The nurse should not add or approve any other complimentary therapies unless directed so by the physician.

During an office visit, a 55-yr-old female pt asks why she has not been prescribed a daily dose of aspirin. Her 56-yr-old husband has been advised by the physician to take a daily aspirin. What can the nurse explain is the most likely reason for this? 1. The benefit of aspirin in women under age 65 is not clear. 2. Aspirin is not recommended for women. 3. This must have been an oversight. 4. She has other meds that could interfere

Answer: 1 Rationale 1: In women, the benefit of low-dose aspirin in reducing the risk for coronary heart disease is not clear prior to 65 years of age. Rationale 2: Aspirin is recommended for women over the age of 65. Rationale 3: This was not an oversight. Rationale 4: There is not enough info to determine if the pt has other meds that could interfere with aspirin.

Following a transmural myocardial infarction, which ECG change stays with the pt for life? 1. Q wave deepening 2. ST segment elevation 3. ST segment depression 4. P wave inversion

Answer: 1 Rationale 1: The development of an abnormal Q wave is a definitive diagnostic sign of myocardial necrosis. Since it is indicative of necrosis, it stays with the pt for life. Rationale 2: ST segment elevation represents myocardial ischemia, which is reversible by increasing the blood flow to the heart. Rationale 3: ST segment depression occurs when muscle ischemia involves only a portion of the heart wall. Rationale 4: P wave inversion represents a junctional pacemaker in the heart & is not related to changes that occur with a myocardial infarction.

A pt who is prescribed atorvastatin (Lipitor) should be monitored for which occurrence? 1. liver enzyme alteration 2. blood glucose & uric acid level alteration 3. renal function alteration 4. sudden back pain & constipation

Answer: 1 Rationale 1: The nurse should be observing lab work for the current cholesterol level & to ensure that liver enzymes remain normal. Rationale 2: Blood glucose & uric acid level are generally not associated with the use of this drug. Rationale 3: Renal function alteration is generally not associated with the use of this drug. Rationale 4: Constipation & sudden back pain are generally not associated with the use of this drug

The nurse, caring for a pt diagnosed with Prinzmetal's or variant angina, realizes this is a serious type of chest pain. Why is this so? 1. It indicates presence of coronary artery spasm. 2. It indicates there is associated renal disease. 3. It indicates there is associated pulmonary disease. 4. It indicates the presence of a myocardial infarction.

Answer: 1 Rationale 1: Variant, Prinzmetal's, or vasospastic angina is a serious type of angina. It occurs when single or multiple sites in major coronary arteries & their large branches have vasospasm, thereby cutting off the blood supply to an area of the myocardium. Rationale 2: Prinzmetal's angina does not occur due to renal disorders. Rationale 3: Prinzmetal's angina does not occur due to a pulmonary disorder. Rationale 4: Prinzmetal's angina is not specifically diagnostic for a myocardial infarction.

A 52-year-old obese male pt who is admitted with elevated triglycerides & a history of smoking two packs of cigarettes a day for 20 years asks about his risk for coronary artery disease. What info should the nurse provide? 1. He is at risk for coronary artery disease. 2. He is not at risk for coronary artery disease. 3. He possesses all nonmodifiable risk factors for coronary artery disease that cannot be overcome. 4. He possesses all modifiable risk factors for coronary artery disease that can be overcome.

Answer: 1 Rationale 1,2,3,4: Age is a nonmodifiable risk factor & obesity, elevated triglycerides & smoking are modifiable risk factors. Together the risk factors place the pt at higher risk to develop coronary artery disease.

The nurse is assessing a pt who is currently experiencing chest pain. The pt has a previous diagnosis of chest pain but now reports an increase in the frequency & duration. Appropriate nursing care for this type of chest pain includes which nursing intervention? 1. aspirin 325 mg PO per day per physician prescription 2. bed rest with bathroom privileges 3. aluminum hydroxide (Maalox) 5 mL PO PRN per physician prescription 4. atropine (Atropair) 0.4 mg IVP PRN per physician prescription

Answer: 1 Rationale 1: Aspirin is considered helpful due to its antiplatelet effects. Rationale 2: Bed rest with bathroom privileges would not necessarily be indicated in this situation. Rationale 3: Antacids are used to treat heartburn or upset stomach. Rationale 4: Atropine (Atropair) is used to dry secretions & stimulate cardiac function, not for chest pain.

The nurse, caring for a pt admitted w/ chest pain, realizes that which factor places the pt at the highest risk for heart disease? 1. overweight & carries the weight around the waist 2. mother died at age 70 of an acute myocardial infarction 3. a single mother of four young children with a low income 4. has a desk job & works long hours

Answer: 1 Rationale 1: Fat accumulation in the upper body, giving the body an appearance of an "apple," has been linked to a greater risk of coronary artery disease (CAD) as opposed to a "pear" shape with body fat accumulation in the gluteofemoral region. Abdominal obesity is associated with elevated levels of cholesterol & greater risk for CAD. Rationale 2: If the pt's mother had died before age 55, that would be a risk factor. Rationale 3: Being a single mother is not a specific risk factor for the development of CAD. Rationale 4: Sedentary life style is a risk factor, but not as significant as fat accumulation in the upper body.

Nursing care of the pt after thrombolytic therapy focuses on the assessment of which finding that is the most common complication? 1. bleeding 2. reperfusion chest pain 3. lethargy 4. heart block

Answer: 1 Rationale 1: Hemorrhage or bleeding is the most common complication; it can be life-threatening. Rationale 2: Recurrent chest pain is not associated with thrombolytic therapy. Rationale 3: Lethargy is not associated with thrombolytic therapy. Rationale 4: Heart block is not associated with thrombolytic therapy.

The nurse is teaching a pt about coronary artery bypass surgery. Which statement, included in this teaching, is essential for the pt to understand? 1. "You must still reduce or modify cardiac risk factors." 2. "This surgery prolongs life on an average of two years." 3. "You have only a minimal chance of functional improvement, even with this surgery." 4. "This surgery will cure your atherosclerosis."

Answer: 1 Rationale 1: It is essential that the pt understand that the goal of the surgery is to relieve the symptoms & improve the quality of life. The pt must still reduce or modify controllable risk factors to retard the underlying process. Rationale 2: Research indicates that life expectancy is prolonged by greater than 15 years following CABG. Less than 10% of pts who undergo CABG will need subsequent revascularization within five to seven years. Rationale 3: CABG provides more complete revascularization & show better long-term relief of symptoms than percutaneous coronary interventions. Rationale 4: The surgery is not done to cure atherosclerosis.

Which is the priority nursing intervention for a pt with a junctional escape rhythm? 1. Assess the pt for symptoms associated with this rhythm. 2. Contact the physician immediately for emergency orders. 3. Eliminate caffeine from the diet. 4. Prepare for a pacemaker insertion.

Answer: 1 Rationale 1: Junctional escape rhythms may be monitored if the pt is not symptomatic. It is most important to assess the pt to see how they are affected by the rhythm. Rationale 2: Then, calling the physician to report the rhythm may be appropriate. Rationale 3: Eliminating caffeine is not an appropriate action for this pt with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given. Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this pt with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given.

The pt asks the nurse about metabolic syndrome. Which is the most accurate answer for the nurse to provide? 1. "Metabolic syndrome is caused by obesity, physical inactivity, & genetic factors." 2. "This syndrome is not a concern for females unless they smoke." 3. "This problem affects only older adults over the age of 65." 4. "It can be avoided by taking vitamins daily & drinking 64 fluid ounces of water a day."

Answer: 1 Rationale 1: Metabolic syndrome is caused by obesity, physical inactivity, & genetic factors. Rationale 2: The syndrome is not directly related to smoking. Rationale 3: The syndrome is not directly related to age. Rationale 4: Daily vitamin & fluid consumption have not been found to alter the syndrome.

Upon auscultating the chest of a 75-year-old pt who recently experienced a myocardial infarction (MI) the nurse hears an S3 & lung crackles. Because of these findings, the nurse would assess for which other condition? 1. heart failure 2. extension of the MI 3. renal failure 4. liver failure

Answer: 1 Rationale 1: S3 & lung crackles are indications of heart failure. Rationale 2: Manifestations of MI extension include chest pain & a return of positive lab finding (CPK-MB & troponin). Rationale 3: Renal failure is a late complication of heart failure & is not manifested with an S3 & crackles. Rationale 4: Liver failure is not manifested with an S3 & crackles.

The family of a pt who experienced a stroke after CABG surgery asks the nurse what caused the stroke to occur. The nurse's best response would be which of the following? 1. "Stroke is usually caused by a blood clot that brakes loose & travels to the brain." 2. "Stroke is usually caused by ruptured plaque inside the coronary artery." 3. "Stroke is caused by heart failure." 4. "No one knows what causes strokes."

Answer: 1 Rationale 1: Stroke is usually caused by an embolus from the ascending aorta or aortic arch, which travels through the heart into the vessels leading to the brain. Rationale 2: Plaque inside a coronary artery would travel downstream & lodge in a smaller vessel in the heart. Rationale 3: Heart failure does not cause a stroke. Rationale 4: Stating that no one knows what causes strokes is not a true statement; blood clots & ruptured vessels cause strokes.

The nurse, caring for a pt recovering from an acute myocardial infarction, realizes that the final extent of cardiac damage is dependent upon which factor? 1. reperfusion of the ischemic zone 2. pt's ethnicity 3. pt's gender 4. development of heart block

Answer: 1 Rationale 1: Surrounding the area of infarction is the zone of injury & the zone of ischemia. These zones are made of potentially viable tissues. They can become necrotic & die, or be reperfused & remain functional. The goal of treatment for an AMI is to establish reperfusion as early as possible to prevent necrosis & salvage the myocardium. Rationale 2: The pt's ethnicity does not impact the final extent of cardiac damage. Rationale 3: The pt's gender does not impact the final extent of cardiac damage. Rationale 4: Developing a heart block does not impact cardiac damage.

The nurse, assessing a middle-aged pt experiencing chest pain, realizes that presence of which symptoms would be most characteristic of an acute myocardial infarction? 1. substernal pressure type pain, radiating down the left arm 2. colic-like epigastric pain 3. sharp, well-localized unilateral chest & left arm pain 4. sharp, burning chest pain moving from place to place

Answer: 1 Rationale 1: Terms such as burning, crushing, suffocating, & pressure are typical descriptors of chest pain from myocardial ischemia, often with pain radiating to other areas of the upper torso. Rationale 2: Cardiac chest pain is not usually described as colic-like, localized to a defined spot such as the epigastric area, or as a sharp pain. Rationale 3: Cardiac chest pain is not usually described as localized to a defined spot or as a sharp pain. Rationale 4: Cardiac chest pain is not usually described as a sharp pain.

A pt reports chest pain, nausea, & vomiting off & on for the last 4 days, which the pt interpreted as the flu. Which lab tests will provide info about acute cardiac damage for this pt? 1. Troponin I & T 2. Red blood cells 3. CPK-MB 4. Homocysteine & platelets

Answer: 1 Rationale 1: The levels of Troponin T begin to rise within 3-6 hours after myocardial injury & remain elevated 14-21 days. Levels of Troponin I begin to increase in about 3-5 hours after myocardial ischemia & peak at 14--18 hours & remain elevated for 5--7 days. Rationale 2: Red blood cells are unaffected by acute cardiac damage. Rationale 3: The CPK-MB rises within 3-6 hours after the MI, peaks within 12-24 hours & levels return to normal 2-3 days following the infarction. This pt would most likely have normal valves 4 days out from the onset of symptoms. Rationale 4: Homocysteine does not change with acute cardiac damage. Platelets are unaffected by acute cardiac damage.

What info does the nurse consider when administering medication to treat hyperlipidemia? 1. Such meds include the statins, which act by lowering LDL levels. 2. These meds act by increasing the LDL levels & decreasing the HDL levels. 3. These meds do not include angiotensin-converting enzyme (ACE) inhibitors. 4. Such meds include bile acid sequestrants as first-line drugs to lower cholesterol levels.

Answer: 1 Rationale 1: The statin drugs specifically lower LDL. Rationale 2: Hyperlipidemia drugs are meant to lower LDL & raise HDL, not the opposite. Rationale 3: Angiotensin-converting enzyme (ACE) inhibitors are appropriate to add to drug treatment for high-risk pts. Rationale 4: Bile acid sequestrant drugs are not first-line drugs but may be added to statins when combination treatment is needed.

The nurse completed teaching related to dietary management of coronary heart disease (CHD). Effective teaching would be indicated by which pt statement? 1. "I can lower my trans fatty acids by switching to the soft margarines & vegetable spreads." 2. "I will watch my fiber intake so I don't get too much." 3. "Well, I'll just have to go buy some of that coconut oil to cook with." 4. "Drinking a couple of glasses of milk each day will give me better protein."

Answer: 1 Rationale 1: Trans fatty acids behave like saturated fats & are found in solid vegetable fats (margarine, shortening) & stick butter, therefore the use of soft margarines & vegetable spreads is recommended for managing CHD. Rationale 2: Other dietary recommendations include reduced intake of saturated fats & cholesterol & increased soluble & insoluble fiber in the diet. Rationale 3: High proportions of saturated fats are found in coconut oil & red meats. Rationale 4: High proportions of saturated fats are found in whole-milk products.

The nurse, caring for a pt with myocardial damage, would expect which change on the ECG tracing? 1. ST segment elevation 2. loss of P waves 3. bradycardia 4. widening of the QRS complex

Answer: 1 Rationale 1: Transmural damage is present with ST segment elevation. Rationale 2: Loss of P waves occurs with atrial flutter & fibrillation. Rationale 3: Bradycardia can be a normal or abnormal rhythm. It's not specifically associated w/ transmural damage. Rationale 4: Widening of the QRS complex occur with bundle branch block. It is not specifically associated with transmural damage.

The nurse is caring for an adult pt who is admitted with chest pain that began four hours ago. Which test will be most specific in identifying acute heart damage? 1. troponin 2. CPK 3. CK-MB 4. cholesterol

Answer: 1 Rationale 1: Troponin is primarily located in cardiac muscle & can indicate myocardial infarction or unstable angina. Troponin elevates at two to four hours after myocardial infarction. Rationale 2,3: CPK & CK-MB will elevate with myocardial damage, but will take longer to rise & are not as specific as troponin. Rationale 4: Cholesterol level is not helpful in diagnosis of myocardial damage.

During pt teaching about cardiac risk factors, the nurse knows that which laboratory test, if abnormal, requires further instruction due to the risk for the development of coronary artery disease? 1. elevated homocysteine 2. elevated creatinine 3. elevated high density lipoprotein (HDL) 4. elevated INR

Answer: 1 Rationale 1: Elevated levels of homocysteine (Hyc > 15 µmol/L) are associated with an increased risk of coronary artery disease (CAD). Homocysteine is an amino acid that is a by-product of the enzyme reactions from meat, dairy products, vitamin, & mineral metabolism. Homocysteine causes endothelial ulceration & scarring, & increases procoagulant properties of blood, all leading to an increase in the risk of thrombus formation. Rationale 2: Elevated creatinine indicates kidney disease. Rationale 3: HDL is the good cholesterol & when elevated it will decrease the risk for the development of CAD. Rationale 4: INR is a laboratory test that measures blood clotting function, not CAD.

A pt, recovering from coronary artery bypass graft (CABG) surgery, tells the nurse that it feels good to be cured of heart disease. Which of the following is the most appropriate response for the nurse to make? Select all that apply. 1. "The surgery only relieves the symptoms; it does not cure the disease." 2. "You must continue to modify your cardiac risk factors." 3. "You are correct; your heart is now normal." 4. "You should not ever exercise again." 5. "There no need to monitor your fat intake any longer."

Answer: 1,2 Rationale 1: Denial is a common coping mechanism with cardiac pts; therefore, it is essential that the nurse stress that CABG is not a cure for coronary artery disease (CAD). Rationale 2: Atherosclerosis is a progressive disease; therefore, the pt needs to continue to modify risk factors. Rationale 3: CABG only relives symptoms, it does not cure the disease. Rationale 4: The pt should begin a cardiac rehabilitation program with a progressive exercise program. Rationale 5: The pt must continue to modify risk factors such as fat intake.

Which of the following should the nurse do to assist a pt recovering from cardiovascular surgery who is demonstrating chest tube output of greater than 100 mL per hours? (Select all that apply.) 1. Report to the surgeon. 2. Check the hemoglobin & hematocrit. 3. Administer a blood transfusion. 4. Notify the family.

Answer: 1,2 Rationale 1: It's abnormal to have > 100 mL of drainage in 1hr. It may indicate bleeding & needs to be assessed by the surgeon. Rationale 2: Hemoglobin & hematocrit should be checked. Rationale 3: The pt needs to be assessed along with the lab data before it is determined if a blood transfusion is necessary. Rationale 4: There is no need to notify family until the pt has been assessed. It may not be of significance.

A pt enters the ER complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this pt includes which nursing actions? Select all that apply. 1. morphine intravenously & oxygen 2. aspirin 325 mg orally 3. open heart surgery 4. heparin drip at 100 units per hour 5. Foley catheter insertion

Answer: 1,2 Rationale 1: The mnemonic MONA, cited in the Advanced Cardiac Life Support (ACLS) guidelines, describes a protocol for treatment of pts with suspected myocardial infarction. The mnemonic stands for morphine, oxygen, nitroglycerin, & aspirin. While the mnemonic does not imply a correct sequencing of treatment, it does describe a protocol for treatment of pts with suspected myocardial infarction. Rationale 2: The mnemonic MONA, cited in the Advanced Cardiac Life Support (ACLS) guidelines, describes a protocol for treatment of pts with suspected myocardial infarction. The mnemonic stands for morphine, oxygen, nitroglycerin, & aspirin. While the mnemonic does not imply a correct sequencing of treatment, it does describe a protocol for treatment of pts with suspected myocardial infarction. Rationale 3: Open heart surgery may be indicated later, but not on admission to the ER. Rationale 4: Heparin is not part of the admission protocol. Rationale 5: A Foley catheter is not part of the admission protocol.

Coronary heart disease (CHD) is a major problem in the United States. Pts with which history may require closer evaluation for CHD? Select all that apply. 1. diabetes 2. hyperlipidemia 3. positive family history 4. a premenopausal woman 5. hypotension

Answer: 1,2,3 Rationale 1: Diabetes is a disease condition that contributes to coronary heart disease (CHD). Rationale 2: Hyperlipidemia is a disease condition that contributes to CHD. Rationale 3: Positive family history in some cases is considered a nonmodifiable risk factor for CHD. Rationale 4: Women experiencing premature menopause (not premenopausal women) is also a condition to be evaluated. Rationale 5: Hypotension is not associated with development of CHD.

The nurse is caring for a pt who develops atrial fibrillation with a heart rate above 100 bpm. Place the following nursing actions in sequence from the highest priority to the lowest priority. Click & drag the options below to move them up or down. Choice 1. Assess the pt for comfort level & vital signs. Choice 2. Check the patency of an intermittent IV. Choice 3. Check the pt's chart for lab results from today's tests. Choice 4. Call the physician to report the dysrhythmia.

Answer: 1,2,3,4 Rationale 1: Assess the pt first. Rationale 2: Check the patency of the IV in case it is needed for anticipated medication administration. Rationale 3,4: Check for lab results prior to calling the physician in order to respond to the physician's questions before the physician gives prescriptions.

22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Teach the patient the reasons for remaining on bed rest. b. Monitor the patient's BP every hour. c. Adjust the drip rate to keep the systolic BP >90 mm Hg. d. Call the health care provider about a decrease in urine output.

B Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output. Cognitive Level: Application Text Reference: pp. 827-829 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture.

B Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle). Cognitive Level: Application Text Reference: p. 822 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload. Cognitive Level: Application Text Reference: pp. 827-828 Nursing Process: Planning NCLEX: Physiological Integrity

7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

B Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy. Cognitive Level: Application Text Reference: p. 828 Nursing Process: Evaluation NCLEX: Physiological Integrity

16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. Cognitive Level: Application Text Reference: pp. 832-833 Nursing Process: Assessment NCLEX: Physiological Integrity

3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

C Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate. Cognitive Level: Application Text Reference: p. 836 Nursing Process: Diagnosis NCLEX: Physiological Integrity

Aspirin has been prescribed for a pt following a myocardial infarction. What should the nurse include in teaching about this drug? 1. Check with your healthcare provider before taking any herbal remedies. 2. Report any itching that develops after seven days of taking the drug. 3. Take at a different time of day than warfarin (Coumadin). 4. Do not skip any scheduled appointments to have blood drawn for labs.

Correct Answer: 1 Rationale 1: Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. Rationale 2: Itching is not a common side effect of aspirin therapy. Rationale 3: Aspirin & Coumadin are not to be taken concurrently. Rationale 4: No lab appointments will be made just for aspirin therapy.

Which diagnostic test would the nurse anticipate as priority for a pt admitted with chest pain to determine coronary heart disease status? 1. coronary angiography 2. stress electrocardiography 3. echocardiography 4. radionuclide testing

Correct Answer: 1 Rationale 1: The gold standard for evaluating coronary arteries is coronary angiography. Visualization of the arteries is allowed with this method. Rationale 2,3,4: The other tests may be used, but are not the primary exam. The remaining exams will probably not be done until the angiography is completed & analyzed.

The nurse is assessing a pt who is six hours postoperative from coronary artery bypass graft (CABG) surgery. The pt's heart rate is 120, bp is 90/50, urine output is decreased, chest tube output is decreased, heart sounds are muffled, & peripheral pulses are diminished. What action should be taken by the nurse first? 1. Notify the physician immediately. 2. Recheck vital signs in 15 minutes. 3. Reposition the pt. 4. Increase the intravenous fluids.

Correct Answer: 1 Rationale 1: The pt is exhibiting signs of cardiac tamponade. This is an emergency, & the Dr. must be notified immediately. Rationale 2: Delaying the response by waiting 15 minutes will be ineffective. Rationale 3: Repositioning the pt will be ineffective. Rationale 4: No change in intravenous fluids should be made until a physician order is given to do so.

Fifteen hours after admission, a pt's CPK-MB level is markedly increased. What does this indicate to the treatment team? 1. Cellular necrosis of myocardial tissue has occurred. 2. Lactic acid is present. 3. Thrombolytic therapy is indicated. 4. Cardiac function has returned to normal.

Correct Answer: 1 Rationale 1: CPK-MB is the intracellular enzyme that is released when cell damage & death occur. CPK-MB becomes elevated when myocardial cell death has occurred. Rationale 2: The pH is the indicator of lactic acid buildup. Rationale 3: Thrombolytic therapy is indicated within the first 12 hours after symptoms develop, thus, it is too late for this intervention. Rationale 4: Cardiac function has not returned to normal.

The nurse, discussing coronary heart disease risk factors with a group of factory employees, would include which option(s) as modifiable risk factors? Select all that apply. 1. hypertension 2. diabetes mellitus 3. obesity 4. age 5. heredity

Correct Answer: 1,2,3 Rationale 1: A person can make a choice to modify HTN by controlling it through meds, weight control, diet, & exercise. Rationale 2: A person can make a choice to modify DM by controlling it through meds, weight control, diet, & exercise. Rationale 3: A person can make a choice to obesity by controlling it through meds, weight control, diet, & exercise. Rationale 4: Hereditary effects on coronary heart disease cannot be changed. Rationale 5: Aging effects on coronary heart disease cannot be changed.

The nurse realizes that the pt in the critical care area with ventricular tachycardia will require which action? Select all that apply. 1. immediate assessment & probable emergency intervention by the nurse 2. cardioversion, if sustained & symptomatic 3. probable administration of a potassium channel blocker 4. close observation for one hour prior to calling the physician 5. defibrillation to convert the rhythm in the awake pt

Correct Answer: 1,2,3 Rationale 1: The nurse should immediately assess the pt to see how the potentially life-threatening rhythm is being tolerated. Rationale 2: The nurse should be prepared to cardiovert the pt in ventricular tachycardia with a pulse according to standing prescriptions. The nurse in critical care needs to be aware of standing prescriptions for each pt prior to an emergent event & needs to have the necessary emergency equipment & meds ready. Rationale 3: Class III antidysrhythmic meds (potassium channel blockers) are typically administered. Rationale 4: Observation prior to calling a physician is not an appropriate action when a potentially life-threatening rhythm is identified. Rationale 5: Defibrillation is only conducted in ventricular tachycardia when the pt is pulseless; otherwise, time is taken to synchronize for cardioversion.

17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation NCLEX: Physiological Integrity

4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

D Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response. Cognitive Level: Application Text Reference: p. 825 Nursing Process: Evaluation NCLEX: Physiological Integrity

12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products.

D Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. Cognitive Level: Application Text Reference: p. 833 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance