EXAM 3 Acute Coronary Syndrome (LEWIS Med-Surg EAQs)

The nurse provides discharge teaching to a patient who is newly diagnosed with coronary artery disease (CAD). Which statement made by the patient indicates understanding of the dietary modifications that need to be implemented after discharge home? 1. "I will not eat bacon or any pork products." 2. "I will eat only fried eggs instead of boiled eggs." 3. "I may continue to enjoy french fries with hot dogs." 4. "I will drink no more than one glass of whole milk per day."

1. "I will not eat bacon or any pork products." (Nutritional guidelines recommended for the patient with CAD include a low-cholesterol and low-fat diet; therefore the patient has to avoid bacon and any pork products. Egg yolk is high in cholesterol and the patient with CAD has to avoid fried food. French fries are high in fat because of their preparation process. Low-fat or nonfat milk is recommended for the patient with CAD.)

A patient with acute coronary syndrome (ACS) receives a prescription for niacin to treat hyperlipidemia. The nurse observes another care provider giving information about the medication to the patient. The nurse should question which item that was included in the education? 1. "Most side effects subside with time." 2. "Take the drug on an empty stomach." 3. "Decreased liver function may occur with high doses." 4. "A side effect is flushing and pruritus in the upper torso and face."

2. "Take the drug on an empty stomach." (The drug should be taken with food. Side effects include flushing and pruritus in the upper torso and face as well as gastrointestinal (GI) disturbances. Most side effects subside with time. Decreased liver function may occur with high doses.) p. 707

A patient with ventricular dysfunction receives a prescription for an angiotensin-converting enzyme (ACE) inhibitor. The nurse should monitor the patient for which indication of medication intolerance? 1. Constipation 2. Hyperactivity 3. Persistent cough 4. Decreased potassium levels

3. Persistent cough A nonproductive and persistent cough may occur in 5% to 25% of individuals. It may take up to two weeks or longer for coughing to subside after the ACE inhibitor is discontinued. If one ACE inhibitor causes coughing, then it is likely that the others will also. Other side effects of ACE inhibitors include diarrhea (versus constipation), drowsiness (versus hyperactivity), and elevated (versus decreased) blood potassium levels.

Which is a characteristic of a complicated lesion? 1. Formation of a fibrous plaque 2. Lipid-filled smooth muscle cells 3. Platelet aggregation and adhesion 4. Transport of lipids into arterial intima

3. Platelet aggregation and adhesion (A complicated lesion is characterized by accumulation of platelets leading to thrombus formation. Formation of a fibrous plaque is the beginning of progressive changes in the endothelium of the arterial wall. It is called the fibrous plaque stage. Fatty streaks are the earliest lesions of atherosclerosis and are characterized by lipid-filled smooth muscle cells. Transport of lipids into the arterial intima occurs in the fibrous plaque stage.)

Upon taking a lipid-lowering medication for hyperlipidemia, a patient reports muscle pain. The nurse notes the patient has elevated liver enzymes and creatine kinase levels. It is most likely that the patient takes which lipid-lowering medication? 1. Niacin 2. Colestipol 3. Simvastatin 4. Gemfibrozil

3. Simvastatin (Muscle pain and elevated creatine kinase levels are manifestations of rhabdomyolysis. Elevated liver enzymes and rhabdomyolysis are adverse effects of statin drugs such as simvastatin. Side effects of niacin include pruritus and flushing. High doses of this drug may cause decreased liver function. Gemfibrozil is a fibric acid derivative that can cause rhabdomyolysis when given with a statin drug. Colestipol is a bile-acid sequestrant drug. This drug does not have any major adverse effects except that it lowers the absorption of drugs such as warfarin, digoxin, and thiazide diuretics. Colestipol is not related to rhabdomyolysis.)

For which patient conditions is coronary revascularization with coronary artery bypass graft (CABG) surgery recommended? Select all that apply. 1. Severe aortic stenosis 2. Failed medical management 3. Left main coronary artery or three-vessel disease 4. Not candidates for percutaneous coronary intervention (PCI) 5. Failed PCI with continued chest pain

Failed medical management, left main coronary artery or three-vessel disease, not candidates for percutaneous coronary intervention (PCI), and failed PCI with continued chest pain. Coronary revascularization with CABG is recommended for patients who have diabetes mellitus, have left main coronary artery or three-vessel disease, patients who are not candidates for percutaneous intervention and who have failed percutaneous intervention and continue to have chest pain, and those who are expected to have longer-term benefits with this surgery than with catheterization. Severe aortic stenosis is not an indicator for cardiac revascularization surgery. p. 715

The nurse reviews the medical records of four patients with chest pain. Which patient would likely benefit from nitroprusside and intraaortic balloon pump (IABP) therapy? 1. Patient A 2. Patient B 3. Patient C 4. Patient D

Showing symptoms of dyspnea, pulmonary edema, and decreased cardiac output, Patient C may have papillary muscle dysfunction and is at risk for clinical deterioration. This patient must be given nitroprusside and IABP therapy to reduce the afterload on the heart. Patient A may have Dressler syndrome, which is treated by short-term corticosteroids. Patient B is exhibiting signs of acute pericarditis, which is treated by aspirin and nonsteroidal antiinflammatory agents. Patient D may have heart failure and may require intensive care. P. 720

The nurse is caring for a patient who survived sudden cardiac death (SCD) caused by a lethal ventricular dysrhythmia. Which tests will likely be prescribed to monitor the effectiveness of drug treatment? Select all that apply. 1. 24-hour Holter monitoring 2. Implantable cardiac monitor 3. MRI 4. Signal-averaged electrocardiogram (ECG) 5. Electrophysiologic study (EPS) under fluoroscopy

1. 24-hour Holter monitoring 4. Signal-averaged electrocardiogram (ECG) 5. Electrophysiologic study (EPS) under fluoroscopy

In which location would a myocardial infarction (MI) occur due to blockage of the right coronary artery? 1. Inferior wall 2. Anteroseptal 3. Anterolateral 4. Anterior wall

Inferior wall Blockage of the right coronary artery may result in an inferior wall MI because the right coronary artery supplies blood to the inferior wall of the heart. Damage to one or more other coronary arteries may result in anteroseptal and anterolateral MIs. Anterior wall infarctions result from blockages in the left anterior descending artery. p. 718

Which artery is most commonly used for coronary bypass grafts? 1. Radial 2. Gastroepiploic 3. Inferior epigastric 4. Internal mammary

Internal mammary Bypass graft surgery involves the replacement of blood vessels that transport blood between the aorta and the blocked coronary artery. The internal mammary artery (IMA) is the most common artery used for bypass graft. The long-term patency rate for an IMA graft is greater than 90% after 10 years. Procedures involving the radial, gastroepiploic, or inferior epigastric artery have a comparatively short-term patency rate. p. 716

The nurse is reviewing a patient's lipid profile results. Which level increases the patient's risk of coronary artery disease (CAD)? 1. Decreased triglycerides 2. Elevated low-density lipoproteins (LDL) 3. Elevated high-density lipoproteins (HDL) 4. Decreased very-low-density lipoproteins (VLDL)

2. Elevated low-density lipoproteins (LDL) (Elevated LDLs contain more cholesterol than any of the other lipoproteins and have an affinity for arterial walls. Elevated LDL levels correlate most closely with an increased incidence of atherosclerosis and CAD. Elevated HDL, decreased triglycerides, and VLDL are all negative risk factors for CAD).

The nurse recalls that which artery is most commonly used for bypass graft? 1. Radial artery 2. Gastroepiploic artery 3. Inferior epigastric artery 4. Internal mammary artery

4. Internal mammary artery (Bypass graft surgery involves the replacement of blood vessels that transport blood between the aorta and the blocked coronary artery. The internal mammary artery (IMA) is the most common artery used for bypass graft. The long-term patency rate for an IMA graft is greater than 90 percent after 10 years. Procedures involving the radial, gastroepiploic, or inferior epigastric artery have a comparatively short-term patency rate.)

The nurse provides education to a patient who receives a prescription for sublingual nitroglycerin for treatment of angina. Which statement made by the patient indicates the need for further teaching? 1. "I cannot take sildenafil and nitroglycerin at the same time." 2. "After the bottle is open, the tablets should be replaced every 12 months." 3. "After taking a tablet, I may experience a headache, dizziness, or flushing." 4. "I can take a tablet 5 to 10 minutes before starting an activity that causes angina."

"After the bottle is open, the tablets should be replaced every 12 months." After the bottle is open, the tablets lose potency and should be replaced every 6 months. Patients should be instructed not to combine nitroglycerin with drugs used for erectile dysfunction (e.g., sildenafil [Viagra]) because severe hypotension can occur. Headache, dizziness, or flushing may occur after taking the medication. The patient can take the medication prophylactically before starting an activity that is known to cause angina. In these cases, the patient can take a tablet or spray 5 to 10 minutes before beginning the activity. p. 711-712

The nurse is caring for a patient with a myocardial infarction. The health care provider prescribes an intravenous infusion of alteplase. What is the priority nursing intervention during the administration of this medication? 1. Assess neurologic status 2. Observe for bleeding gums 3. Monitor blood pressure for orthostatic changes 4. Apply a pressure dressing to IV insertion site

1. Assess neurologic status (Assessment for changes in neurologic status is the priority nursing intervention because this may indicate a cerebral bleed. Gingival or bleeding gums are expected with thrombolytic therapy and are controlled by applying ice packs. Application of a pressure dressing to the IV insertion site is not done until evidence of bleeding is noted. Monitoring blood pressure for orthostatic changes is necessary with the use of short-acting nitrates.)

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication? 1. Dysrhythmias 2. Anxiety and fear 3. Metabolic acidosis 4. Medication side effects

1. Dysrhythmias (The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. The nurse should also be alert for increased anxiety, which may cause pain and lead to a secondary infarction. Anxiety and fear are highly likely but secondary in importance to monitoring the patient for dysrhythmias. Metabolic acidosis and reactions to new medications are not likely but should still be included as part of overall assessment of the patient.)

The nurse assesses a patient with diabetes who reports shortness of breath, neck pain, and hypoglycemic symptoms. The patient's BP is 130/86 mm Hg, heart rate is 102 beats/min, respiratory rate is 24 breaths/min, and the finger-stick blood glucose is 136 mg/dL. Which condition would the nurse suspect? 1. Myocardial infarction (MI) 2. Late-stage diabetic ketoacidosis 3. Early-onset diabetic ketoacidosis 4. Hyperosmolar hyperglycemic nonketotic syndrome

1. Myocardial infarction Signs and symptoms of an MI include shortness of breath, neck pain, and cool, clammy skin. Although cool, clammy skin may resemble a hypoglycemic reaction, when found along with shortness of breath and neck pain it is very specific for an MI. The patient is not experiencing a complication of diabetes (ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome). The blood glucose is close to normal, and further diagnostics would be required to determine a diabetic complication. P. 719

Cardiac biomarker levels are being evaluated for a patient who is suspected of having a myocardial infarction (MI). The nurse recognizes that which biomarker lacks specificity and that its role in diagnosing an MI is limited? 1. Myoglobin 2. Creatine kinase-MB (CKMB) 3. Cardiac-specific troponin (cTnl) 4. Cardiac-specific troponin T (cTnT)

1. Myoglobin (Myoglobin is a serum cardiac marker that is released into the circulation within two hours after a myocardial infarction (MI). Myoglobin's role in diagnosing MI is limited because it lacks cardiac specificity. Creatine kinase-MB (CKMB) levels begin to rise about six hours after an MI, are specific to myocardial cells, and help quantify myocardial damage. Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) are highly specific indicators of MI.)

A patient with a history of unstable angina reports a sudden onset of retrosternal chest heaviness and tightness, fatigue, shortness of breath, and nausea. Which actions would the nurse take? Select all that apply. 1. Obtain a 12-lead electrocardiogram (ECG). 2. Administer sublingual nitroglycerin. 3. Place the patient in a supine position. 4. Apply high-flow oxygen by face mask. 5. Auscultate for a pericardial friction rub.

1. Obtain a 12-lead electrocardiogram (ECG). 2. Administer sublingual nitroglycerin. Initial management of the patient with chest pain includes the following: Obtain a 12-lead ECG and start continuous ECG monitoring. Position the patient in an upright, not supine, position unless contraindicated, and initiate oxygen by nasal cannula (not high-flow by face mask) to keep oxygen saturation above 93%. Establish an IV route to provide an access for emergency drug therapy. Give sublingual nitroglycerin and aspirin (chewable). Morphine sulfate is given for pain unrelieved by nitroglycerin (NTG). Auscultating for a pericardial friction rub is not an appropriate action. P. 722

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? 1. Oxygen, nitroglycerin, aspirin, and morphine 2. Aspirin, nitroprusside, dopamine, and oxygen 3. Nitroglycerine, lorazepam, oxygen, and warfarin 4. Oxygen, furosemide, nitroglycerin, and meperidine

1. Oxygen, nitroglycerin, aspirin, and morphine (The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Furosemide, meperidine, nitroprusside, dopamine, lorazepam, and warfarin may be used later in the patient's treatment.)

A patient experiences mild chest pain during inspiration, while coughing, and while performing daily activities. Sitting in a forward position relieves the pain. The nurse identifies that the patient is experiencing what complication of myocardial infarction? 1. Pericarditis 2. Left-sided heart failure 3. Ventricular aneurysm 4. Papillary muscle dysfunction

1. Pericarditis (Chest pains experienced during inspiration, coughing, and performing activities that goes away upon sitting forward indicate acute pericarditis in the patient. Left-sided heart failure occurs initially with subtle signs such as mild dyspnea, restlessness, agitation, or slight tachycardia. A ventricular aneurysm may result from thinning of the infarcted myocardial walls. Papillary muscle dysfunction occurs when the infarcted area includes the papillary muscle that attaches to the mitral valve.) p. 721

The nurse provides basic physical activity guidelines for a patient that is being discharged following acute coronary syndrome (ACS). The nurse recommends following the FITT formula, which includes which guidelines? 1. Physical activity that is regular, rhythmic, and repetitive 2. An increase in heart rate of 25 beats/minute over the resting heart rate 3. Physical activity sessions that begin at 5 to 10 minutes and build up to 45 minutes. 4. Mild weightlifting for 10 minutes to allow stretching of muscles before exercising

1. Physical activity that is regular, rhythmic, and repetitive (The FITT formula includes physical activities that are regular, rhythmic, and repetitive, using large muscles to build up endurance. The increase in heart rate (HR) should not exceed 20 beats/min over the resting HR. The physical activity session should build up to 30 minutes. There is no weightlifting included in the formula.)

The nurse provides information about thrombolytic therapy to a group of student nurses. Which statement made by a student nurse indicates the need for further teaching? 1. "Significant head trauma within the past three months is a relative contraindication." 2. "A symptom of major bleeding with thrombolytic therapy is an increase in heart rate (HR)." 3. "The goal is to give the thrombolytic within 30 minutes of the patient's arrival to the emergency department." 4. "The most reliable sign of blood flow restoration is the return of the ST segment to baseline on the electrocardiogram (ECG)."

1. Significant head trauma within the past three months is a relative contraindication. Significant closed-head or facial trauma within the past three months is an absolute contraindication due to increased risk of bleeding; the benefit does not outweigh the risk. Signs and symptoms of bleeding during thrombolytic therapy include a drop in BP, increase in HR, sudden change in the patient's mental status, and blood in the urine or stool. Treatment of ST-segment-elevation myocardial infarction (STEMI) with thrombolytic therapy aims to limit the infarction size by dissolving the thrombus in the coronary artery and reperfusing the heart muscle rapidly. The most reliable sign of blood flow restoration is the return of the ST segment to baseline on the ECG. P. 725

Which factor leads to total occlusion of the coronary artery? 1. Thrombus formation in the coronary artery 2. Transport of cholesterol into the arterial intima 3. Smooth muscle proliferation of the arterial wall 4. Lipid-filled smooth muscle cells in the coronary artery

1. Thrombus formation in the coronary artery (A thrombus may form and adhere to the wall of the coronary artery, leading to total occlusion. The transport of cholesterol into the arterial intima may lead to the formation of plaques on one portion of the artery, or in a circular fashion involving the entire lumen. Smooth muscle proliferation may lead to the thickening of the arterial wall. The earliest lesions are fatty streaks characterized by lipid-filled smooth muscle cells.)

A patient tells the nurse, "I had severe chest pain six days ago." The nurse identifies that which cardiac biomarker will be most helpful in determining whether the patient had a myocardial infarction at the time the patient experienced chest pain? 1. Troponin 2. Myoglobin 3. Homocysteine 4. Creatine kinase

1. Troponin (Troponin is a serum cardiac marker that is detectable in the blood up to two weeks after myocardial injury and is used to diagnose a myocardial infarction. Troponin has two subtypes: cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI). Serum levels of cTnT and cTnI increase 4 to 6 hours after the onset of myocardial injury, peak at 10 to 24 hours, and return to baseline over 10 to 14 days. Myoglobin is a protein found in skeletal and cardiac muscle. It is a sensitive indicator of early myocardial injury but is not specific for cardiac muscle; therefore it is not used to diagnose a myocardial infarction. Myoglobin peaks and returns to normal in 3 to 15 hours. Homocysteine is a protein. High levels of homocysteine may indicate an increased risk for coronary artery disease. It is not used to diagnose myocardial infarction. CK levels begin to rise about 6 hours after an MI, peak at about 18 hours, and return to normal within 24 to 36 hours.) p. 721

The nurse teaches a student nurse about acute pericarditis. Which statement made by the student nurse indicates effective learning? 1. "I should massage the patient's chest region to relieve symptoms." 2. "The patient's pain can be relieved by sitting in the forward position." 3. "Acute pericarditis should be treated immediately by IV heparin." 4. "Treatment of acute pericarditis involves mitral valve repair or replacement."

2. "The patient's pain can be relieved by sitting in the forward position." Acute pericarditis is an inflammation of the pericardium that may occur within two to three days of acute myocardial infarction. The patient's chest pain is relieved after sitting in the forward position. The pain may return after a change in position or inspiration. Massaging the chest region may aggravate the symptoms. IV heparin is given to a patient with an unstable thrombus or coronary artery spasm. Papillary muscle dysfunction treatment involves mitral valve repair or replacement. Acute pericarditis treatment involves nonsteroidal antiinflammatory agents, aspirin, and corticosteroids. P. 721

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed? 1. Delegated to the health care provider 2. Discussed along with other physical activities 3. Avoided because it is embarrassing to the patient 4. Accomplished by providing the patient with written material

2. Discussed along with other physical activities (Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. The discussion of sexual activity should not be delegated to the health care provider or avoided because of embarrassment. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns. )

The nurse assesses a patient who has been administered the tissue-type plasminogen activator alteplase for an acute myocardial infarction. Which assessment finding is the highest priority and should be reported to the primary health care provider immediately? 1. Anorexia 2. Hematuria 3. Oral temperature of 100. 4 F (38 C) 4. Occasional premature ventricular contractions

2. Hematuria (Alteplase is a proteolytic enzyme that digests threads and other substances in the blood, including clotting factors, thereby causing hypercoagulability of the blood and possibly bleeding, which is evidenced by blood in the urine. Anorexia and increased temperature are not issues directly related to this drug. Alteplase may cause premature ventricular contractions, which should be monitored, but this is usually not a problem because the drug has a short half-life.)

A nurse is caring for a patient with a history of chronic stable angina that reports chest pain. What is a characteristic of pain related to this type of angina? 1. It generally lasts longer than 15 to 20 minutes. 2. It will be relieved by rest, nitroglycerin, or both. 3. It is frequently associated with vomiting and extreme fatigue. 4. It indicates that irreversible myocardial damage is occurring.

2. It will be relieved by rest, nitroglycerin, or both. (Chronic stable angina is characterized by intermittent chest pain, often described as pressure or tightness that occurs over a period of time in the same pattern, onset, and intensity. It commonly subsides when precipitating factors have stopped and the patient is at rest or with the use of nitroglycerin. The pain usually lasts just 5 to 15 minutes and does not always indicate irreversible myocardial damage. Vomiting and extreme fatigue are symptoms of myocardial infarction and are not commonly seen in chronic stable angina.)

The nurse is examining the electrocardiogram (ECG) of a patient who has just been admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion? 1. Sinus tachycardia 2. Pathologic Q wave 3. Fibrillatory P waves 4. Prolonged PR interval

2. Pathological Q wave The presence of a pathologic Q wave, which often accompanies ST-segment-elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses p. 720

Which behaviors can help reduce psychologic risk factors that contribute to the development of coronary artery disease (CAD)? Select all that apply. 1. Monitoring glucose levels daily 2. Setting realistic goals for exercise 3. Changing eating patterns and habits 4. Increasing activities to a prescribed fitness level 5. Planning time for adequate rest and sleep 6. Learning effective stress management techniques

2. Setting realistic goals for exercise 5. Planning time for adequate rest and sleep 6. Learning effective stress management techniques (Planning time for adequate rest and sleep contributes to the patient's psychologic well-being, which can reduce the risk for development of CAD. Setting realistic goals for exercise also increases psychologic well-being, because reaching attainable goals can help boost the patient's level of confidence. Learning effective stress management techniques helps reduce the risk for development of CAD by helping the patient better manage his or her stress levels. Increasing activities to a prescribed fitness level, monitoring glucose levels daily, and managing eating patterns and habits are all appropriate behaviors to aid in the reduction of risk factors for CAD, but they address physiologic, not psychologic, components.)

In caring for the patient with angina the patient states, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever. It was similar to the pain I had at home. The pain went away rather quickly." What further assessment data should the nurse obtain from the patient? 1. "What precipitated the pain?" 2. "Has the pain changed this time?" 3. "In what areas did you feel this pain?" 4. "Rate the pain on a scale from 0 to 10."

3. "In what areas did you feel this pain?" (Using PQRST, the assessment data not volunteered by the patient is the radiation (R) of pain, the area in which the patient felt the pain and if it radiated. The precipitating event (P) was going to the bathroom and having a bowel movement. The quality of the pain (Q) was "like before I was admitted," although a more specific description may be helpful. Severity of the pain (S) was the "worst chest pain ever," although an actual number may be needed. Timing (T) is supplied by the patient describing when the pain occurred and that the patient had had this pain previously.) p. 708

What instruction should the nurse give to the patient who is predisposed to coronary artery disease (CAD)? Select all that apply. 1. "Avoid consuming tofu." 2. "Drink whole or 2% milk." 3. "Limit concentrated fruit juice." 4. "Decrease intake of beans." 5. "Choose foods such as buckwheat and oats."

3. "Limit concentrated fruit juice." 5. "Choose foods such as buckwheat and oats." (Concentrated fruit juices are high in added sugar and should be limited. Buckwheat and oats are made whole grain and are recommended. Beans are a good source of fiber and are recommended. The AHA recommends eating tofu because it contains alpha-linolenic acid, which becomes omega-3 fatty acid in the body. Patients should select fat free or low fat dairy products.)

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning? 1. "A nitroprusside stress echocardiogram is used for patients with acute pericarditis." 2. "A pathogenic Q wave is always present in the electrocardiogram (ECG) of patients with unstable angina." 3. "Serum cardiac markers are proteins that are released from necrotic heart muscle." 4. "Coronary angiography is the only way to confirm the diagnosis of unstable angina."

3. "Serum cardiac markers are proteins that are released from necrotic heart muscle." (Serum cardiac markers such as myoglobin, creatine kinase, cardiac-specific troponin I (cTnI), and cardiac-specific troponin T (cTnT) are released in patients with myocardial infarction (MI) into the blood from necrotic heart muscle. These markers are important to diagnose MI. A patient with a pathologic Q wave and ST-elevated MI has prolonged coronary occlusion because the MI evolves with time. Pharmacologic stress echocardiogram testing with dobutamine, dipyridamole, or adenosine simulates the effects of exercise and is performed on patients who are unable to exercise or have abnormal, nondiagnostic baseline echocardiograms. A coronary angiography is used for patients with stable or high-risk unstable angina.)

A patient who is being discharged from the hospital after acute coronary syndrome will be participating in cardiac rehabilitation. Which information will the nurse provide about the early recovery phase of rehabilitation? 1. Activity level depends on severity of angina or myocardial infarction (MI). 2. Therapeutic lifestyle changes should become lifelong habits. 3. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring. 4. The focus will be on management of chest pain, anxiety, dysrhythmias, and other complications.

3. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is increased gradually under supervision and with ECG monitoring. In the first phase of recovery, activity is dependent on the severity of the angina or MI. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too. P. 726

A patient that is being discharged from the hospital after acute coronary syndrome will be participating in cardiac rehabilitation. What information should the nurse provide about the early recovery phase of rehabilitation? 1. Therapeutic lifestyle changes should become lifelong habits. 2. Physical activity always begins in the hospital and continued at home. 3. Activity level is increased gradually with supervision by the rehabilitation team and with ECG monitoring. 4. The focus of rehabilitation will be on management of chest pain, anxiety, dysrhythmias, and other complications.

3. Activity level is increased gradually with supervision by the rehabilitation team and with ECG monitoring. (In the early recovery phase after the patient is dismissed from the hospital, the activity level is increased gradually under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or myocardial infarction (MI), and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.)

The nurse reviews a patient's medical record and notes documentation of what condition that refers to arterial anastomoses or connections? 1. Atheromas 2. Angiogenesis 3. Collateral circulation 4. Coronary artery disease

3. Collateral circulation (Collateral circulation occurs when arterial anastomoses or connections are formed. Coronary artery disease is a type of blood vessel disorder that is included in the general category of atherosclerosis. Atheromas are fatty deposits that are formed in coronary arteries. Angiogenesis is an inherited disposition to develop new blood vessels.)

The rupture of plaque in the artery occurs in which stage of the pathogenesis of arterial disease? 1. Fatty streak 2. Fibrous plaque 3. Complicated lesion 4. Chronic endothelial injury

3. Complicated lesion (The rupture of plaque in the artery occurs when the lesion is complicated. The plaque ruptures, and thrombus formation occurs, as does further narrowing or total occlusion of the vessel. Fibrous plaque occurs when collagen covers the fatty streak, narrowing the artery, thus reducing the blood flow. When the fatty streak forms, lipids accumulate and migrate into the smooth muscle cells. Chronic endothelial injury occurs secondary to exposure of toxins, infections, and certain disease processes.)

The nurse assesses a patient with papillary muscle dysfunction. Which observation supports the patient's diagnosis? 1. Crackles 2. S3 heart sound 3. Murmur at the cardiac apex 4. Deep sound noted while auscultating at the lower sternal border.

3. Murmur at the cardiac apex (Papillary muscle dysfunction occurs if the papillary muscles attached to the mitral valves are involved in infarction. A patient may have papillary muscle infraction if a murmur is heard upon auscultation at the cardiac apex. The presence of crackles of breath sounds and S3 and S4 sounds of the heart indicate heart failure. The deep sound heard at the lower left sternal border upon auscultation indicates acute pericarditis.)

The nurse recognizes that which medication(s) may relieve spasms associated with radial artery coronary artery bypass surgery? Select all that apply. 1. Captopril 2. Carvedilol 3. Nicardipine 4. Verapamil 5. Tenecteplase

3. Nicardipine 4. Verapamil (The radial artery is a thick muscular artery that is prone to spasm. A patient with coronary revascularization of the radial artery is administered long-acting nitrates and calcium channel blockers treatment. Nicardipine and verapamil are calcium channel blockers that will help to control the spasms. Captopril, an ACE inhibitor, prevents ventricular remodeling and prevents the progression of heart failure in a patient with elevated ST-segment myocardial infarction. Carvidilol, a beta blocker, helps reduce workload on the heart. Tenecteplase stops the infarction in a patient with myocardial infarction (MI) by dissolving the thrombus and reperfusing the myocardium.)

The nurse provides information to a patient about ways to decrease risk factors for coronary artery disease (CAD). Which statement by the patient indicates understanding of the teaching? 1. "I will add weightlifting to my daily exercise program." 2. "I will change my diet to increase my intake of saturated fats." 3. "I need to switch to smokeless tobacco instead of smoking cigarettes." 4. "I will change my lifestyle to alter patterns that add to my stress."

4. "I will change my lifestyle to alter patterns that add to my stress." (Health-promoting behaviors for those at risk for CAD include: physical activity such as brisk walking (three to four miles/hour for at least 30 minutes five or more times a week); reducing total fat and saturated fat intake; stopping all tobacco use, and altering patterns that are conducive to stress.)

The nurse is providing care to a patient with chronic stable angina that is scheduled for a cardiac catheterization. What finding associated with myocardial ischemia could be obtained by this diagnostic procedure? 1. ST segment depression 2. Cardiac enlargement 3. Abnormal cardiac wall motion 4. 70% block in right coronary artery

4. 70% block in right coronary artery (Cardiac catheterization is an invasive diagnostic procedure to find out the location and severity of blockages in the coronary circulation. ST segment depression is an important diagnostic finding for the presence of myocardial ischemia, which is obtained by electrocardiography (ECG). Cardiac enlargement is a sign of heart failure that can be seen on an x-ray. Echocardiography is used to detect the presence of abnormal wall motion due to myocardial ischemia.)

The nurse is caring for a patient 24 hours after the patient was diagnosed with ST segment elevation myocardial infarction (STEMI). The nurse should monitor the patient for what complication of myocardial infarction (MI)? 1. Unstable angina 2. Cardiac tamponade 3. Sudden cardiac death 4. Cardiac dysrhythmias

4. Cardiac dysrhythmias (The most common complication after MI is dysrhythmias, which are present in 80 percent of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.)

To reduce a patient's risk of coronary artery disease (CAD), the nurse recognizes that dietary teaching is needed when the patient's high density lipoprotein (HDL) and low-density lipoprotein (LDL) profile reveals what two abnormal results? 1. Increased HDLs, increased LDLs 2. Decreased HDLs, decreased LDLs 3. Increased HDLs, decreased LDLs 4. Decreased HDLs, increased LDLs

4. Decreased HDLs, increased LDLs (The risk of CAD is associated with increased LDLs (> 160 mg/dL) and decreased HDLs (< 40 mg/dL))

What is an appropriate nursing intervention for a patient who smokes cigarettes and is predisposed to developing coronary artery disease? 1. Recommend smokeless tobacco 2. Encourage the use of filtered cigarettes 3. Suggest smoking low nicotine cigarettes 4. Discuss medication to assist with smoking cessation

4. Discuss medication to assist with smoking cessation (The patient must be encouraged to quit smoking. Smoking cessation medications such as bupropion can be used to prevent the withdrawal symptoms of nicotine. Even if the patient is using smokeless tobacco, the risk of developing coronary artery disease is the same. Changing to filtered cigarettes does not affect the risk of developing coronary artery disease. Changing from high-nicotine to low-nicotine cigarettes also does not affect the risk of getting coronary heart disease.)

Which is considered a nonmodifiable risk factor for coronary artery disease? 1. Obesity 2. Diabetes 3. Tobacco use 4. Family history of heart disease

4. Family history of heart disease (Family history of heart disease is a nonmodifiable risk factor for coronary artery disease. Diabetes, obesity, and tobacco use are all considered modifiable risk factors for coronary artery disease.)

A patient with Prinzmetal's angina who takes a short-acting nitrate reports feeling dizzy while changing positions. What prescription does the nurse anticipate? 1. Esmolol 2. Morphine sulfate 3. IV heparin 4. IV fluid bolus

4. IV fluid bolus (Prinzmetal's angina is treated with short-acting nitrates, such as nitroglycerin. Orthostatic hypotension is a common side effect of nitroglycerin because of the depletion of body fluid volume. Therefore the patient must be administered intravenous fluid bolus. Beta blockers such as esmolol can lead to hypotension, which may further worsen the patient's condition. Intravenous heparin is administered to a patient undergoing thrombolytic therapy; heparin is not suggested for a patient with Prinzmetal's angina. Morphine sulfate is the drug of choice for chest pain during angina that is unrelieved by nitroglycerin.)

A patient experienced sudden cardiac death (SCD) while hospitalized and survived. The nurse expects that what preventive treatment will be prescribed? 1. External pacemaker 2. An electrophysiologic study (EPS) 3. Medications to prevent dysrhythmias 4. Implantable cardioverter-defibrillator (ICD)

4. Implantable cardioverter-defibrillator (ICD) (An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital, but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used, but are not best for prevention of SCD.) p. 730 **The most common approach to preventing a recurrence is the use of an ICD. It has been shown that an ICD improves survival compared with drug therapy alone. Drug therapy and a PCI will not prevent a recurrence of SCD. A CABG is not necessary.

A patient survived an episode of sudden cardiac death (SCD) and is recovering in the intensive care unit (ICU). The nurse anticipates which intervention to prevent a recurrence? 1. Drug therapy with beta-blocker 2. Coronary arter bypass graft (CABG) 3. Precutaneous coronary intervention (PCI) 4. Implantable cardioverter-defibrillator (ICD)

4. Implantable cardioverter-defibrillator (ICD) (The most common approach to preventing a recurrence is the use of an ICD. It has been shown that an ICD improves survival compared with drug therapy alone. Drug therapy and a PCI will not prevent a recurrence of SCD. A coronary artery bypass graft is not necessary.)

The nurse is reviewing a plan of care for emergency treatment of a patient with chest pain. Which item listed on the plan would the nurse question? 1. Give a high-dose statin medication. 2. Give 162 to 325 mg aspirin (chewable). 3. Start O2 by nasal cannula to keep O2 saturation above 93%. 4. Instruct the patient to do coughing and deep-breathing exercises

4. Instruct the patient to do coughing and deep-breathing exercises Rapid diagnosis and providing treatment to a patient with acute coronary syndrome help to preserve cardiac muscle function. The initial treatment is to manage chest pain; therefore the patient needs to rest and limit activities (including breathing exercises) for 12 to 24 hours. The nurse should make sure that the oxygen saturation stays at an acceptable level by initiating supplemental oxygen. Aspirin is part of the antiplatelet therapy. Statins are lipid-lowering drugs. They block synthesis of cholesterol and increase low-density lipoprotein receptors in the liver. P. 723, 726

A patient who has received a maximum dose of nitroglycerin continues to report chest pain. What is the next medication that the nurse should administer to the patient? 1. Esmolol 2. Docusate 3. Ticagrelor 4. Morphine sulfate

4. Morphine Sulfate (Morphine sulfate is the drug of choice for a patient with unrelieved chest pain even after the administration of nitroglycerin. Esmolol is a beta blocker used to slow down the heart during minimally invasive direct coronary artery bypass (MIDCAB). Docusate is a stool softener that facilitates bowel movements. Ticagrelor is used in dual antiplatelet therapy on a patient with ongoing angina and negative cardiac markers.)

The nurse observes a student nurse who is providing thrombolytic therapy to a patient three hours after the patient's report of chest pain. Which action performed by the student nurse indicates the need for the nurse to intervene? 1. Monitors the patient for blood in the urine 2. Assesses the patient regularly for neurologic status changes 3. Draws blood samples from the patient before initiation of therapy 4. Reduces the dose of the thrombolytic agent during episodes of chest pain

4. Reduces the dose of the thrombolytic agent during episodes of chest pain (Thrombolytic therapy helps stop the infarction process by dissolving the thrombus in the coronary artery and reperfusing the myocardium. In order to be effective, the entire dose of a thrombolytic agent must be administered as soon as possible after the onset of symptoms. Unless contraindicated, the patient should be provided with heparin intravenously (IV) along with other thrombolytic therapy to dissolve the unstable thrombus and reduce spasms in the coronary artery. A major complication of the thrombolytic therapy is bleeding; therefore the nurse should monitor the urine and stool for bleeding. Monitoring for neurologic changes in the patient helps assess for cerebral bleeding. The nurse should draw the blood samples from the patient before initiation of the therapy to assess the baseline laboratory values.)

A patient asks the nurse about resuming sexual activity after acute coronary syndrome (ACS). What should the nurse include in the patient's teaching plan? 1. Take a hot shower just before intercourse to provide relaxation. 2. Limit the time, including foreplay, to 30 minutes to prevent overexertion. 3. Wait an hour after ingesting a large meal before engaging in sexual activity. 4. Taking a prophylactic nitrate may decrease chest pain during sexual activity.

4. Taking a prophylactic nitrate may decrease chest pain during sexual activity. (Taking a prophylactic nitrate may decrease chest pain during sexual activity. Hot or cold showers should be avoided just before or after intercourse. Consumption of food and alcohol should be reduced before intercourse is anticipated (e.g., waiting 3-4 hours after ingesting a large meal before engaging in sexual activity). There is no established time limit. Foreplay is desirable because it allows a gradual increase in heart rate before orgasm.)

For which problem is percutaneous coronary intervention (PCI) initially indicated? 1. Chronic stable angina 2. Left-sided heart failure 3. Acute myocardial infarction 4. Coronary artery disease (CAD)

Acute myocardinal infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure. p. 712

Which type of medication may be prescribed for a patient with an ejection fraction (EF) of 25%? 1. Lipid-lowering agent 2. β-adrenergic blocker 3. Calcium channel blocker 4. Angiotensin-converting enzyme (ACE) inhibitor

Angiotensin-converting enzyme (ACE) inhibitor Patients with chronic stable angina who have an EF of 40% or less should take an ACE inhibitor indefinitely, unless contraindicated. These drugs result in vasodilation and reduced blood volume. They also prevent ventricular remodeling and prevent the progression of heart failure in the patient. Lipid-lowering agents reduce low density cholesterol and triglyceride levels in the blood. β-adrenergic blockers decrease myocardial oxygen demand by reducing heart rate, BP, and contractility. Calcium channel blockers are prescribed to decrease BP in patients with β-blocker intolerance and Prinzmetal's angina.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 712

Which drug class includes clopidogrel? 1. Opioid analgesic 2. Antiplatelet agent 3. Vitamin K antagonist 4. Nonsteroidal antiinflammatory drug (NSAID)

Antiplatelet agent Clopidogrel (Plavix) is an antiplatelet agent used commonly in patients with cardiovascular disease. Plavix is not an opioid analgesic, vitamin K antagonist, or NSAID.Test-Taking Tip: Bring to your test prep a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

A patient reports heaviness and burning sensation in the substernal and retrosternal region. Which assessment finding would indicate sympathetic nervous system stimulation? 1. Jugular venous distention 2. Abnormal S3 and S4 sounds 3. Ashen, clammy, and cool skin 4. Shortness of breath and anxiety

Ashen, clammy, and cool skin A patient with heaviness and burning sensation in the substernal and retrosternal region may be having a myocardial infarction (MI) and stimulation of the sympathetic nervous system. This condition may trigger the production of catecholamines, which promote glycogen release, diaphoresis, and vasoconstriction of peripheral blood vessels. Because of this, the patient's skin may appear ashen, clammy, and cool to the touch. Jugular vein distention and abnormal S3 and S4 sounds are caused by ventricular dysfunction. Shortness of breath and anxiety may not necessarily be caused by sympathetic nervous system stimulation.Test-Taking Tip: Recollect the manifestations of sympathetic versus parasympathetic responses to be able to differentiate between the two. p. 719

A patient receives morphine sulfate to relieve chest pain. For which adverse effects would the nurse monitor the patient? Select all that apply. 1. Bradypnea 2. Dysrhythmias 3. Bradycardia 4. Hypotension 5. Decreased ejection fraction

Bradypnea, hypotension Morphine sulfate is prescribed to patients with chest pain. Morphine acts as a vasodilator; it decreases cardiac workload, contractility, and BP. The nurse should monitor for signs of bradypnea and hypotension to avoid myocardial ischemia and infarction. The nurse should monitor dysrhythmias and bradycardia in a patient receiving docusate. Morphine sulfate does not directly affect ejection fraction; indirectly, improved oxygenation will lead to more effective cardiac pumping.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 725

The nurse provides a list of health-promoting regular physical activity examples to a patient with coronary artery disease (CAD). Which activity would the nurse include on the list? 1. Painting while seated 2. Performing carpentry 3. Jogging (7 to 8 miles per hour) 4. Brisk walking (3 to 4 miles per hour)

Brisk walking (3 to 4 miles per hour) Physical activity improves the physiologic functioning and psychologic well-being of a patient with acute coronary syndrome. Therefore the nurse should encourage the patient to walk at a rate of 3 to 4 miles per hour. Painting while seated is a low-energy activity. Carpentry and running at 7 miles per hour are high-energy activities for a patient with acute coronary syndrome.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 728

A patient is scheduled for coronary artery bypass graft (CABG) surgery. Which type of graft, if used, would require postoperative antiplatelet and statin therapy to improve graft patency? 1. Radial artery graft 2. Saphenous vein graft 3. Gastroepiploic artery graft 4. Internal mammary artery graft

CABG involves the replacement of conduits that transport blood between the aorta and the coronary artery. A patient with a saphenous vein graft may develop intimal hyperplasia, which contributes to stenosis and graft occlusions. This patient should receive antiplatelet therapy and statins after surgery to improve vein graft patency. A patient with radial artery CABG should receive calcium channel blockers and long-acting nitrates to control coronary spasms. A patient with gastroepiploic artery CABG generally has a high graft patency rate; the chances of graft-related problems are very rare. A patient with CABG of the internal mammary artery has an average graft patency of more than 90%, even after 10 years. A patient with high graft patency rates may not require any medication to maintain the patency of the graft. P. 716

The nurse auscultates a new murmur at the cardiac apex in a patient who has had a myocardial infarction. Which treatment strategies would the nurse expect may be included in the patient's collaborative care plan? Select all that apply. 1. Antiplatelet agents 2. Short-term corticosteroids 3. Cardiac surgery with mitral valve repair 4. Intraaortic balloon pump (IABP) therapy 5. Nonsteroidal antiinflammatory drugs (NSAIDs)

Cardiac surgery with mitral valve repair and Intraaortic balloon pump (IABP) therapy Papillary muscle dysfunction is a complication of myocardial infarction and should be suspected if a new murmur at the cardiac apex is detected. It may occur if the infarcted area includes or is near the papillary muscle that attaches the mitral valve. The patient should be treated with nitroprusside, IABP therapy, or cardiac surgery with mitral valve repair to reduce the afterload of the heart. Antiplatelets, such as aspirin and NSAIDs, help treat acute pericarditis. Short-acting corticosteroids are effective in the treatment of Dressler syndrome. p. 720

In addition to troponin levels, which laboratory result in a patient's health record is most indicative of myocardial infarction? 1. Increased myoglobin 2. Increased C-reactive protein 3. Increased creatine kinase-MB (CK-MB) 4. Increased white blood cell count

Increased creatine kinase-MB (CK-MB) Biochemical markers, such as creatine kinase (CK) and troponin are released specifically by myocardial cells when injured and are detectable in the blood. The CK enzymes are fractionated into bands. The CK-MB is specific to heart muscles and helps to quantify myocardial damage. Myoglobin, although one of the first markers to increase after a myocardial infarction (MI), does not have as high of a cardiac specificity as others. C-reactive protein is increased after an MI as a result of the inflammation caused by tissue damage; however, it is also not as highly specific to cardiac tissue. An increased white blood cell count may be present after an MI but is due to a generalized inflammatory response. P. 721

A patient has had a myocardial infarction (MI) in the past 24 hours. Which potential complication would a nurse assign the highest priority for monitoring? 1. Dysrhythmias 2. Anxiety and fear 3. Metabolic acidosis 4. Medication side effects

Dysrhythmias The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. The nurse should also be alert for increased anxiety, which may cause pain and lead to a secondary infarction. Anxiety and fear are highly likely but secondary in importance to monitoring the patient for dysrhythmias. Metabolic acidosis and reactions to new medications are not likely but should still be included as part of overall assessment of the patient. p. 720

Which symptoms in a 55-year-old female patient would the nurse recognize as possibly indicating unstable angina? 1. Dyspnea, hyperglycemia, and polyuria 2. Altered mentation with difficulty breathing 3. Fatigue, indigestion, and shortness of breath 4. Peripheral edema with decreased urinary output

Fatigue, indigestion, and shortness of breath An adult female with fatigue, indigestion, and dyspnea may be experiencing an unstable anginal (UA) attack. A patient experiencing dyspnea, hyperglycemia, and polyuria may have diabetes. Altered mentation (confusion) and difficulty breathing could be caused by many conditions, including heart failure exacerbation, sepsis, or UA in an older patient. Peripheral edema with decreased urine output may indicate right heart failure due to a history of UA or coronary artery disease. Test-Taking Tip: A patient should never neglect any signs of myocardial infarction. Educating the public, especially females, is important, to identify the complications early. P. 719

For which reason would a patient with acute coronary syndrome (ACS) be scheduled for an off-pump coronary artery bypass (OPCAB) surgery rather than a traditional surgical approach? 1. It does not involve a sternotomy. 2. It is associated with decreased postoperative spasms. 3. It is associated with less blood loss and less renal dysfunction. 4. It uses a robot to perform the surgery, which allows for increased precision.

It is associated with less blood loss and less renal dysfunction. The OPCAB is a procedure that allows for access to all coronary vessels. OPCAB is useful for patients with multiple comorbidities because it is associated with less blood loss, less renal dysfunction, less postoperative atrial fibrillation, and fewer neurologic complications. It involves a median sternotomy. This type of surgery does not have an advantage of decreased postoperative spasms. The robotic or totally endoscopic coronary artery bypass (TECAB) surgery uses a robot to perform coronary artery bypass grafting (CABG) surgery. P. 716

The nurse is caring for a patient having a myocardial infarction. The health care provider prescribes an IV infusion of alteplase. Which intervention would the nurse include during the administration of this medication? 1. Monitor for changes in neurologic status. 2. Assess BP for orthostatic changes. 3. Apply a pressure dressing to IV insertion sites. 4. Start additional IV lines after alteplase infusion has begun.

Monitor for changes in neurologic status. Assessment for changes in neurologic status is the priority nursing intervention because this may indicate a cerebral bleed during the thrombolytic infusion. Monitoring BP for orthostatic changes is necessary with the use of short-acting nitrates. Application of a pressure dressing to the IV insertion site is not done unless evidence of bleeding is noted. Additional IV therapy lines should be inserted before the alteplase begins. Perform all other invasive procedures before giving the thrombolytic agent to reduce the risk for bleeding. p. 724

Cardiac biomarker levels are being evaluated for a patient who is suspected of having a myocardial infarction (MI). Which biomarker lacks specificity for diagnosing an MI? 1. Myoglobin 2. Creatine kinase-MB (CK-MB) 3. Cardiac-specific troponin I (cTnI) 4. Cardiac-specific troponin T (cTnT)

Myoglobin Myoglobin is a serum cardiac marker that is released into the circulation within two hours after an MI. Myoglobin's role in diagnosing MI is limited because it lacks cardiac specificity. Creatine kinase-MB (CK-MB) levels begin to rise about six hours after an MI, are specific to myocardial cells, and help quantify myocardial damage. Cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI) are highly specific indicators of MI. p. 721

Which therapy would the nurse anticipate administering for emergency care of a patient with a suspected myocardial infarction (MI)? 1. Oxygen, nitroglycerin, aspirin, and morphine 2. Aspirin, nitroprusside, dopamine, and oxygen 3. Nitroglycerin, lorazepam, oxygen, and warfarin 4. Oxygen, furosemide, nitroglycerin, and meperidine

Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Furosemide, meperidine, nitroprusside, dopamine, lorazepam, and warfarin may be used later in the patient's treatment.STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections. p. 712

Diagnostic tests confirm that a patient is experiencing a ST-segment-elevation myocardial infarction (STEMI). For which first line of treatment will the nurse prepare the patient? 1. Antiplatelet and statins therapy 2. Dual antiplatelet therapy and heparin 3. Transmyocardial laser revascularization 4. Percutaneous coronary intervention (PCI)

Percutaneous coronary intervention (PCI) Emergent PCI is the first line of treatment for patients with confirmed STEMI (i.e., ST-elevation on the electrocardiogram [ECG] and/or positive cardiac biomarkers). The goal is to open the blocked artery within 90 minutes of arrival to a facility that has an interventional cardiac catheterization laboratory. Antiplatelet and statins therapy improves vein graft patency in a patient who has undergone coronary artery bypass grafting (CABG) involving the saphenous vein. Dual antiplatelet therapy and heparin will help a patient with ongoing angina and negative cardiac markers. Transmyocardial laser revascularization is used for a patient with advanced coronary artery disease and persistent angina even after maximum medical therapy. p. 718

A patient with Prinzmetal's angina who takes a short-acting nitrate reports feeling dizzy while changing positions. Which prescription would the nurse anticipate? 1. Esmolol 2. Morphine sulfate 3. IV heparin 4. IV fluid bolus

Prinzmetal's angina is treated with short-acting nitrates, such as nitroglycerin. Orthostatic hypotension is a common side effect of nitroglycerin because of the depletion of body fluid volume. Therefore the patient may be administered IV fluid bolus. β-blockers such as esmolol can lead to hypotension, which may further worsen the patient's condition. IV heparin is administered to a patient undergoing thrombolytic therapy; heparin is not suggested for a patient with Prinzmetal's angina. Morphine sulfate is the drug of choice for chest pain during angina that is unrelieved by nitroglycerin. P. 711

A patient is scheduled for a minimally invasive direct coronary artery bypass (MIDCAB). Which steps are involved in the procedure? Select all that apply. 1. A robot is used to replace the mitral valve. 2. Small incisions are made between the ribs. 3. Cardiac catheterization is performed during the procedure. 4. A mechanical stabilizer is placed to immobilize the operative site. 5. A thoracoscope or robotic assistance is used to free the internal mammary artery.

Small incisions are made between the ribs, a mechanical stabilizer is placed to immobilize the operative site, and a thoracoscope or robotic assistance is used to free the internal mammary artery MIDCAB offers patients with disease of the left anterior descending or right coronary artery an approach to surgical treatment that does not involve a sternotomy and cardiopulmonary bypass (CPB). It involves several small incisions between the ribs to dissect the internal mammary artery (IMA) with a thoracoscope or with robotic assistance. The heart is then slowed or stopped temporarily with adenosine, which is assisted by a mechanical stabilizer to immobilize the operative site. The IMA is then sutured to the coronary artery. A robot is used to replace the mitral valve during robot-assisted cardiothoracic surgery. Transmyocardial laser revascularization involves cardiac catheterization. Mechanical stabilizers are used on a beating heart during off-pump coronary artery bypass. p. 716

A patient is admitted to the intensive care unit in stable condition with a diagnosis of myocardial infarction. Which common medications will be used to treat this condition? Select all that apply. 1. Diuretics 2. Stool softeners 3. Prophylactic antibiotics 4. Dual antiplatelet therapy 5. IV nitroglycerin 6. Low -molecular-weight heparin (LMWH)

Stool softeners, dual antiplatelet, IV nitroglycerin, and low molecular weight heparin After an MI, the patient may be predisposed to constipation because of bed rest and opioid drugs. Stool softeners (e.g., docusate sodium [Colace]) prevent straining and the resultant vagal stimulation from the Valsalva maneuver. Vagal stimulation produces bradycardia and can provoke dysrhythmias. Drug therapy for myocardial infarction includes IV nitroglycerin, dual antiplatelet therapy (e.g., aspirin and clopidogrel), and systemic anticoagulation with either LMWH given subcutaneously or IV unfractionated heparin, which are the initial drug treatments of choice for acute coronary syndrome (ACS). Diuretics and prophylactic antibiotics are not appropriate at this time. P. 725-726

A patient phones a health care provider's office and states, "I am having severe chest tightness that won't go away even when I lie down." In addition to contacting emergency responders, which instruction would the nurse provide to the patient? 1. "Lie down with your feet elevated." 2. "Go to a neighbor's house to get assistance." 3. "Take chewable aspirin. The total dose should be 325 mg." 4. "Take your blood pressure. It will be useful to know for your care."

Take a chewable aspirin. The total dose should be 325 mg. The symptoms described by the patient may be due to acute coronary syndrome (ACS). Advise the patient to take chewable aspirin; the dose is 162 to 325 mg (typically 4 baby aspirin or 2 adult aspirin). The patient's BP may be elevated, and lying with the feet elevated will most likely increase the BP. The patient should not increase oxygen demand by walking to a neighbor's house or by taking the BP.