MCA-3 Week 1 Coronary Artery Disease

Question 3 of 25 Which nursing intervention best promotes effective communication?

"Do you feel that you do not need to be involved in your health care?" Clarification of the client's statement is a useful therapeutic technique that encourages further communication.

Question 20 of 25 Fill in the blankThe primary healthcare provider (HCP) prescribes a continuous IV infusion of amiodarone 1 mg/min for the client. The available drug is amiodarone 900 mg in 500 mL of D5W. The nurse should set the IV pump at how many mL/hr? (Enter numerical value only. If rounding is necessary, round to the whole number.)

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Question 23 of 25 Which client should the nurse assess first?

A client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). This is the least stable of the four clients. The nurse needs to assess for the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of an MI.

Question 6 of 25 While taking the prescribed antihyperlipidemic, which serum laboratory value requires intervention?

ALT 60 U/L (1.0 mckat/L). Normal ALT is 4 - 36 U/L (0.07 - 0.60 mckat/L). Antihyperlipidemics can cause increased liver enzymes and should be monitored periodically during treatment.

Question 19 of 25 Which intervention should the nurse initiate first?

Administer amiodarone IV. The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone.

A client 5 days post-MI who is complaining that he is constipated and demands that his healthcare provider (HCP) be called.

Although it is important to ensure that clients avoid straining post-MI, another client requires more immediate assessment.

Auscultate lungs for adventitious sounds such as crackles.

Auscultating the lungs for crackles or other adventitious sounds can reveal pulmonary edema which is a possible complication following an acute myocardial infarction. Pulmonary edema is often gradual and not immediately life threatening.

Avoid drinking caffeine-containing beverages prior to the test.

Caffeine may affect the heart rate, but not as pronounced as nicotine. Caffeine should be reported prior to the test but should not affect the outcome.

Question 17 of 25 Which intervention is most important for the nurse to include in the client's plan of care?

Continuous cardiac monitoring of heart rate and rhythm. The heart rate and rhythm should be continuously monitored. Lethal arrhythmias are the most common immediate complication following an acute myocardial infarction that can be life threatening.

Hang an IV infusion of dopamine.

Dopamine is a vasopressor and inotropic agent that is used to treat severe hypotension and shock. This intervention may be required if the client's dysrhythmia is not controlled and cardiogenic shock develops. However, this is not the best initial action.

Do not drink anything until tablet is completely dissolved.

Drinking may cause some of the medication to be swallowed and not absorbed sublingually, slowing the absorption of the nitroglycerin dose. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets.

Question 16 of 25 The nurse is monitoring the client for complications that are common after a myocardial infarction. Which focused assessment finding warrants immediate intervention by the nurse?

Dysrhythmias. The most common complication after an MI is dysrhythmias. Lethal dysrhythmia often occur within 4 hours from onset of chest pain. Premature ventricular contractions may precede the lethal dysrhythmias ventricular tachycardia and fibrillation.

Question 1 of 25 Which information in the client's history indicates an increased risk for coronary artery disease (CAD) and requires the nurse to provide disease management education? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Episodes of hypoglycemia. Hypoglycemia does not increase the risk for CAD. A history of diabetes mellitus is a contributing risk factor. Family history of hyperlipidemia. Genetic predisposition is a significant factor in the development of CAD. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 306. Consumption of a high fat diet. Unhealthy habits, such as consuming fatty foods, are contributing risk factors to CAD. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 306. Hypertension controlled with an oral antihypertensive. High blood pressure is a modifiable risk factor. If controlled, then it is not an active risk. Smoking two packs of cigarettes per day. Smoking is a modifiable risk factor for coronary artery disease. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 306.

Tell the client to have nothing by mouth four hours before the test.

Food and drink within hours of test may cause nausea and discomfort, but will not affect the outcome of the test.

Encourage intake of oral fluids.

For the first 24 hours following the procedure, intake and output should be monitored, but forcing fluids is not indicated.

Question 4 of 25 Which nursing intervention best promotes effective communication?

HDL less than 50 mg/dL (1.29 mmol/L) for women indicates an increased risk. HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 50 mg/dL (1.29 mmol/L) for women is too low to safeguard the arteries.

Question 11 of 25 ECG findings reveal ST segment elevation in leads II and III, and a VF indicating that the client is having an inferior acute myocardial infarction (AMI). Which intervention should the nurse implement first?

Have the client chew four 81 mg chewable acetylsalicylic acid. The first intervention according to American Heart Association standard is to administer acetylsalicylic acid 160-325 mg PO that acts on the platelets, keeping them from clumping together at the site of the coronary blockage.

Question 5 of 25 After discussing these test results with the healthcare provider (HCP) and the nurse, the client expresses interest in learning how to lower her cholesterol and lose weight. The HCP prescribes the antihyperlipidemic agent lovastatin 20 mg PO daily. Which intervention is most important for the nurse to include in the client's plan of care related to the use of an antihyperlipidemic?

Healthy lifestyle habits Lifestyle modifications should be used in conjunction with a cholesterol-lowering medication. Lifestyle modificatios include heart healthy diet, regular exercise, avoiding tobacco products, and maintaining a healthy weight.

Bilateral pulmonary crackles.

Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening.

Distended jugular vein.

Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening.

Question 10 of 25 Which nursing intervention should be implemented first?

IV access and administer morphine sulfate as ordered by the HCP. Acute chest pain related to myocardial infarction, ischemia, or reduced coronary artery blood flow is the most important nursing problem to address for the client with Acute Coronary Syndrome (ACS). Treating pain is critical, as pain activates the sympathetic nervous system and aggravates diaphoresis, weakness, light-headedness, and palpitations which, in turn, increases cardiac workload.

Question 22 of 25 Which nursing intervention should be implemented first when the client returns to her room?

Immobilize the affected leg. The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill.

Question 12 of 25 The healthcare provider (HCP) orders IV nitroglycerin for the client. What changes in the client's cardiac function should the nurse tell the client to expect?

Improved perfusion of oxygenated blood to the heart muscle. Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen.

An increase in the strength of the heart muscle to contract.

Increasing the force and velocity of myocardial systolic contraction is not an action of nitroglycerin.

Question 9 of 25 The HCP prescribes a stress echocardiogram. When preparing the client for the test, which instruction is most important for the nurse to provide?

Instruct the client not to smoke on the day of the test. The client smokes and should be specifically instructed not to smoke prior to test. Nicotine can interfere with the heart rate.

Provide pamphlet listing non-modifiable risk factors.

Instruct the patient on cardiac risk factors that are modifiable which include smoking cessation, diet, and exercise. Non-modifiable risk factors are good to know but will not increase patient's control of illness.

Limit visitors to one per hour.

Limiting visitors is not routine or necessary, but it should be implemented if the client's comfort or safety is jeopardized.

Encourage the client to maintain complete bedrest

Monitor exercise and provide rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload. Complete bedrest could lead to pulmonary complications.

Question 21 of 25 What steps should the nurse take to minimize the development of these adverse effects? (Select all that apply. One, some, or all options may be correct.)

Monitor serum lidocaine levels. Monitor ECG, blood pressure, and respiratory status. Monitor the client's anxiety level. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL (6.4 to 21.34 mcmol/L). Heart rhythm and VS, especially blood pressure and respirations, must be monitored closely. Nervousness and excitation are adverse effects of lidocaine and the nurse should monitor the client closely for these developments. The infusion must be stopped immediately if signs of overdose are present.

Titrate oxygen to keep oxygen saturation greater than 93%.

Monitoring and titrating oxygen will help provide the myocardial tissue the oxygen it needs to prevent further injury. A gradual drop in oxygen can be managed and is not immediately life threatening.

Obtain blood to evaluate scheduled serum cardiac markers.

Monitoring serum cardiac markers will determine if the mycardial tissue injury is resolving. Knowing the cardiac marker levels will aid in prompt intervention but is a scheduled intervention.

Administer morphine sulfate 4 mg IV.

Morphine is given if pain is unrelieved by the nitroglycerin, according to American Heart Association standard.

Myoglobin 60 mcg/L (3.49 nmol/L).

Myoglobin (Female) 10 - 65 mcg/L (0.58 - 3.78 nmol/L) (onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs).

Dissolves the blockage inside the coronary arteries.

Nitroglycerin is not a thrombolytic and does not dissolve what is blocking the arteries.

Give the client one nitroglycerin tablet to dissolve under her tongue.

Nitroglycerin is the third intervention according to American Heart Association standard, and is given to vasodilate the coronary arteries and relieve pain.

Causes the heart muscle to relax between contractions.

Nitroglycerin perfuses cardiac muscle, but it does not relax the muscle.

Creatine kinase - MB (CK-MB) 3.0 ng/mL (3.0 mcg/L).

Normal CK-MB < 5.0 ng/mL (5.0 ug/L). This is the most sensitive creatine kinase to the cardiac muscle, but is also found in skeletal muscle.

Lactate dehydrogenase (LDH) 200 U/L (3.34 mckat/L).

Normal LDH is 140 U/L (0.67 ukat/L) to 280 U/L (4.68 ukat/L). LDH, like creatine phosphokinase (CPK), is an enzyme that is nonspecific to cardiac muscle injury. However, LDH1 is a sensitive cardiac isoenzyme, which is often compared with LDH2 as a ratio during the diagnosis of MI.

Notched P waves in various leads.

Notched P waves may be evidence of atrial enlargement and should be further evaluated, but is not priority over the myocardial injury that is occuring.

Apply oxygen 2 L/nasal cannula.

Oxygen is the second intervention according to American Heart Association standard, if the client's oxygen saturation level is less than 94%.

Administer oxygen.

Oxygenation to the myocardial tissue is important for pumping activity and tissue damage repair. Rest also helps to improve oxygenation. However, recent guidelines suggest that routine use of supplemental oxygen may not be necessary in clients with uncomplicated ACS without signs of heart failure, hypoxemia, respiratory distress, or for an oxyhemoglobin saturation rate of 94% or greater.

Tall peaked T waves in all leads.

Peaked T waves may indicate an elevated potassium level and should be further evaluated but is not priority over the myocardial injury that is occuring.

Pericardial friction rub.

Pericarditis is a complication that can occur following an acute myocaridal injury. Signs and symptoms include ECG changes including diffuse ST-segment elevations and an audible pericardial friction rub. Pain is aggrivated with inspiration and is typically described differently than classic chest pain. Pericarditis is not immediately life threatening.

Prolonged PR interval measuring 0.22 seconds.

Prolongation of the PR interval is typical of a first-degree AV block, an electrical conduction disturbance within the heart. While development of a conduction block may occur as a result of myocardial injury, the presence of a prolonged PR interval is not itself indicative of myocardial injury.

Question 18 of 25 The client continues to recover in the intensive care unit. Which interventions should the nurse implement for the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Provide pain medication with onset of pain. Administer anti-anxiety medication as needed. Assess the client's level of knowledge and ability to learn. Providing optimal pain relief with prescribed analgesics is important because pain can exacerbate tachycardia and increases blood pressure. Identify when level of anxiety increases. Anxiety increases the need for oxygen. Knowledge related to disease process and prognosis is important but should also be realistic. Realistic expectations promotes realistic decision making.

Question 2 of 25 Which intervention is most important for the nurse to reinforce when assisting the client in achieving their goal to quit smoking?

Provide the client with a list of local smoking cessation programs. Prescribed and over-the-counter medications work best when taken in conjunction with a smoking cessation program. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 1077. Review a list of over-the-counter smoking cessation aids with the client. Over-the-counter medications work best when taken in conjunction with a smoking cessation program. Encourge the client to start taking a prescribed nicotinic agonist. Prescribed medications work best when taken in conjunction with a smoking cessation program. Identify the triggers that cause the client to use nicotine. Even though smokers indicate that they would like to quit, the addictive quality of nicotine makes it very difficult to do so without having support with medication and a program.

Question 7 of 25 Which intervention is most important for the nurse to include in the client's plan of care for the self-administration of sublingual nitroglycerin?

Put one tablet every 5 minutes under tongue up to 3 tablets. Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department.

Question 13 of 25 In addition to nitroglycerin, the HCP orders morphine sulfate 4mg IV. Which reaction requires immediate intervention by the nurse?

Respiratory rate slowing to 10 breaths/min. Profound respiratory depression is an adverse reaction of opioids such as morphine sulfate. Respiratory rate should remain 12 breaths/min or higher.

Question 14 of 25 The client reports an increase in her chest pain as 8 out of 10. The nurse immediately obtains another ECG. Which ECG assessment finding warrants immediate intervention by the nurse?

ST segment elevation and the development of Q waves. ST segment elevation is indicative of acute myocardial injury leading to infarction and requires immediate intervention (STEMI versus non-STEMI - STEMI causes more deaths).

Serum cholesterol under 300 mg/dL (7.77 mmol/L) is considered a healthy heart level.

Serum cholesterol less than 200 mg/dL (5.18 mmol/L) is the desired level.

Charge the defibrillator to 200 joules.

Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action.

Place the crash cart in close proximity to the room.

Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action.

Place one tablet at a time under the tongue.

Sublingual tablets are placed under the tongue. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets.

Allow tablet to dissolve completely before swallowing.

Tablets must completely dissolve to be effective. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets.

Question 8 of 25 When providing education for the prescribed transdermal nitroglycerin, which intervention is most important for the nurse to include?

Tell the healthcare provider (HCP) of persistant dizziness when standing. Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause the client to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. If the dizziness is persistant when standing, the client's blood pressure may be too low, requiring the HCP to adust the dosage or change the medication.

Question 25 of 25 Which expected outcomes indicate that the nurse's discharge teaching was effective? (Select all that apply. One, some, or all options may be correct.)

The client chooses walking as her initial form of exercise. The client chooses a diet low in saturated fat and cholesterol. Walking is the best initial activity/exercise for the post-MI client. The client should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks. A diet low in saturated fat and cholesterol will reduce the risk for the client developing another MI.

Obtain apical pulse every 15 minutes.

The client should be continuously monitored for the onset of any dysrhythmias, but frequent (every 15 minutes) assessment of the apical pulse is not necessary.

Question 24 of 25 The nurse should immediately intervene to prevent violation of which client right?

The right to have information about the qualifications of caregivers. The individuals in the group should wear name tags that clearly identify their roles, they should introduce themselves, and they should explain to the client why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care.

This client, post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds.

This client's condition is stable, and her circulation is strong, so assessment of this client is not the highest priority.

A client recently started on propranolol and aspirin for coronary artery disease.

This client's condition is stable. Propranolol is a beta-blocker frequently used to reduce myocardial oxygen demand, and aspirin is used to reduce the risk of thrombus formation. This client's response to the medications should be monitored, but this is not the nurse's most immediate priority.

Report any redness under the patch site.

This is a common side effect that can be managed by rotating patch application sites.

Expect a mild headache after application.

This is a common side effect that may be more noticeable when applying a new patch.

Inform HCP of rash around the transdermal patch.

This is a common side effect. The HCP should be informed; however, this is not life threatening.

TSH 3.9 mclU/mL (3.9 mIU/L).

This is a normal TSH level. Antihyperlipidemics do not affect thyroid function.

Amylase 44 U/L (0.73 mckat/L).

This is a normal amylase level. Antihyperlipidemics do not affect pancreatic function.

Potassium 4.8 mEq/L (4.8 mmol/L).

This is a normal potassium level. Electrolytes and potassium are not affected by antihyperlipidemic therapy.

The client states that she feels confident about driving herself home from the hospital.

This is not a desired outcome. Clients discharged post-MI can be weak and can become fatigued easily. Activities that could cause straining or excessive stress should be avoided.

The client recognizes the need to avoid all aspirin products.

This is not an expected outcome, unless the client is taking a prescribed anticoagulant, such as warfarin. Daily low-dose aspirin is frequently prescribed to reduce the risk for thrombosis.

The client talks with her husband about avoiding sexual intercourse for the next six months.

This is not an expected outcome. Sexual activity can be resumed once the client's tolerance to activity has been assessed. Generally, once the client can tolerate walking approximately one block or climbing two flights of stairs, intercourse can be resumed. The nurse should instruct the client regarding measures such as positioning, and waiting at least half an hour after eating to avoid undue strain, and using prophylactic nitroglycerin prior to intercourse.

LDL less than 200 mg/dL (5.18 mmol/L) is within an acceptable range.

This is too high. LDL is the "bad" cholesterol that can accumulate in the arteries, eventually leading to angina, infarction, or CVA. Less than 100 mg/dL (2.59 mmol/L) is considered the optimal level, with readings above 190 (4.92 mmol/L) considered very high.

Question 15 of 25 In addition to the ECG, the nurse sent blood to the laboratory to evaluate the client's cardiac isoenzyme. Which serum laboratory values requires intervention by the nurse?

Troponin T 0.4 ng/mL (0.4 mcg/L). Troponin T 0 - 0.2 ng/mL (0.2 ug/L) (onset: 2-4 hrs, peak: 10-24 hrs, return to normal: 10-14 days). This indicates acute myocardial injury and requires immediate intervention.

Wear loose-fitting clothes and good walking shoes.

Wearing loose-fitting clothes and good walking shoes may be more comfortable for completing the test but should not affect the outcome of the test.

Serum cholesterol greater than 200 mg/dL (5.18 mmol/L) requires medical intervention.

While 200 mg/dL (5.18 mmol/L) or less is considered desirable, medical intervention is not generally initiated for levels under 240 mg/dL (6.22 mmol/L). Clients with cholesterol levels between 200 to 240 mg/dl (5.18 - 6.22 mmol/L) should be advised to begin lifestyle modifications.

Obtain a 12 lead electrocardiogram (ECG).

While this intervention will be useful in establishing the client's baseline rhythm upon arrival in the ED, and will be helpful in locating the area of MI, circulation is the third priority for emergency care.