Acute Coronary Syndrome CAD AQ
For which problem is percutaneous coronary intervention (PCI) most clearly indicated? Chronic stable angina Left-sided heart failure Acute myocardial infarction Coronary artery disease (CAD)
Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD normally are treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.
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)? Unstable angina Cardiac tamponade Sudden cardiac death Cardiac dysrhythmias
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.
The nurse monitors a patient for complications of myocardial infarction. The nurse auscultates a new murmur at the cardiac apex. Which treatment strategies are appropriate for inclusion in the patient's care plan? Select all that apply. Antiplatelets Short-term corticosteroids Cardiac surgery with mitral valve repair Intraaortic balloon pump (IABP) therapy Nonsteroidal antiinflammatory agents (NSAIDs)
Cardiac surgery with mitral valve repair 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, intraaortic balloon pump (IABP) therapy, or cardiac surgery with mitral valve repair to reduce the afterload of the heart. Antiplatelets, such as aspirin and nonsteroidal antiinflammatory agents, help treat acute pericarditis. Short-acting corticosteroids are effective in the treatment of Dressler syndrome.
During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication? Dysrhythmias Anxiety and fear Metabolic acidosis 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.
The nurse is examining the 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? Sinus tachycardia Pathologic Q wave Fibrillatory P waves Prolonged PR interval
Pathologic 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.
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? "Most side effects subside with time." "Take the drug on an empty stomach." "Decreased liver function may occur with high doses." "A side effect is flushing and pruritus in the upper torso and face."
"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.
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? "A symptom of major bleeding with thrombolytic therapy is an increase in heart rate." "Significant facial trauma within the past 3 months is a relative contraindication." "The goal is to give the thrombolytic within 30 minutes of the patient's arrival to the emergency department." "The most reliable sign of blood flow restoration is the return of the ST segment to baseline on the ECG."
"Significant facial trauma within the past 3 months is a relative contraindication." Significant closed-head or facial trauma within the past 3 months is an absolute contraindication due to increased risk of bleeding; the benefit does not outweigh the risk. Treatment of STEMI with thrombolytic therapy aims to limit the infarction size by dissolving the thrombus in the coronary artery and reperfusing the heart muscle. 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. The most reliable sign of blood flow restoration is the return of the ST segment to baseline on the ECG.
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? Myoglobin Creatine kinase-MB (CKMB) Cardiac-specific troponin I (cTnI) Cardiac-specific troponin T (cTnT)
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 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? Therapeutic lifestyle changes should become lifelong habits. Physical activity always begins in the hospital and continued at home. Activity level is increased gradually with supervision by the rehabilitation team and with ECG monitoring. The focus of rehabilitation will be on management of chest pain, anxiety, dysrhythmias, and other complications.
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 recognizes that which type of medication may be prescribed for a patient with an ejection fraction of 25%? Lipid lowering agent Beta-adrenergic blocker Calcium channel blocker Angiotensin-converting enzyme (ACE) inhibitor
Angiotensin-converting enzyme (ACE) inhibitor Patients with chronic stable angina who have an ejection fraction (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. Beta-adrenergic blockers decrease myocardial oxygen demand by reducing heart rate, blood pressure, and contractility. Calcium channel blockers are prescribed to decrease blood pressure in patients with beta blocker intolerance and Prinzmetal's angina.
A patient reports chest pain. The nurse should assess for which clinical manifestations associated with a myocardial infarction (MI)? Select all that apply. Flushing Ashen skin Diaphoresis Nausea and vomiting S 3 or S 4 heart sounds
Ashen skin Diaphoresis Nausea and vomiting S 3 or S 4 heart sounds During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S 3 and S 4 heart sounds.
A patient reports heaviness and burning sensation in the substernal and retrosternal region. Assessment findings include a fasting blood glucose of 190 mg/dL and blood pressure of 145/90 mm Hg. The nurse recognizes that which other finding indicates sympathetic nervous system stimulation? Jugular venous distention Abnormal S 3 and S 4 sounds Ashen, clammy, and cool skin 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 S 3 and S 4 sounds are caused by ventricular dysfunction. Shortness of breath and anxiety may not necessarily be caused by sympathetic nervous system stimulation.
The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed? Delegated to the health care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient Accomplished by providing the patient with written material
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.
A patient is admitted to the intensive care unit with a diagnosis of myocardial infarction. The patient is in stable condition. The nurse recognizes what common medications that are used to treat this condition? Select all that apply. Diuretics Stool softeners Prophylactic antibiotics Dual antiplatelet therapy Intravenous (IV) nitroglycerin Low molecular weight heparin (LMWH)
Dual antiplatelet therapy Intravenous (IV) nitroglycerin Low molecular weight heparin (LMWH) Drug therapy for myocardial infarction includes intravenous 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). Oral beta-adrenergic blockers are given after day two if there are no contraindications (e.g., heart failure, heart block, hypotension). Diuretics and prophylactic antibiotics are not appropriate at this time.
The nurse assesses a patient with papillary muscle dysfunction. Which observation supports the patient's diagnosis? Crackles S 3 heart sound Murmur at the cardiac apex Deep sound noted while auscultating at the lower sternal border
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 S 3 and S 4 sounds of the heart indicate heart failure. The deep sound heard at the lower left sternal border upon auscultation indicates acute pericarditis.
The nurse is caring for a patient who survived sudden cardiac death (SCD) that was caused by a lethal ventricular dysrhythmia. The nurse anticipates that which tests will be prescribed to monitor the effectiveness of drug treatment? Select all that apply. Exercise stress testing 24-hour Holter monitoring Magnetic resonance imaging (MRI) Signal-averaged electrocardiogram (ECG) Electrophysiologic study (EPS) under fluoroscopy
Exercise stress testing 24-hour Holter monitoring Signal-averaged electrocardiogram (ECG) Electrophysiologic study (EPS) under fluoroscopy Because most SCD patients have lethal ventricular dysrhythmias associated with a high recurrence rate, they are closely monitored to assess when they are most likely to have a recurrence and to determine which drug therapies are most effective for them. This monitoring includes exercise stress testing, 24-hour Holter monitoring, signal-averaged electrocardiogram, and an electrophysiologic study done under fluoroscopy. Magnetic resonance imaging is not used to monitor for lethal dysrhythmias.
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? Anorexia Hematuria Oral temperature of 100.4° F (38° C) Occasional premature ventricular contractions
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. Text Reference - p. 752
A patient experienced sudden cardiac death (SCD) while hospitalized and survived. The nurse expects that what preventive treatment will be prescribed? External pacemaker An electrophysiologic study (EPS) Medications to prevent dysrhythmias Implantable cardioverter-defibrillator (ICD)
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.
The nurse recalls that which artery is most commonly used for bypass graft? Radial artery Gastroepiploic artery Inferior epigastric artery Internal mammary artery
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.
A patient with Prinzmetal's angina who takes a short-acting nitrate reports feeling dizzy while changing positions. What prescription does the nurse anticipate? Esmolol Morphine sulfate Intravenous heparin Intravenous fluid bolus
Intravenous 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.
The nurse provides a student nurse with information related to management of a patient following cardiac catheterization. The nurse should explain that which intervention is the specific responsibility of the nurse, rather than that of Unlicensed Assistive Personnel (UAP)? Recording vital signs Monitoring neurovascular changes Asking the patient about comfort measures Assisting with oral hygiene, hydration, meals, and toileting
Monitoring neurovascular changes The nurse is responsible for monitoring changes in neurovascular status or bleeding. All members of the health care team can address measures that will make the patient more comfortable. Unlicensed assistive personnel (UAP) take vital signs and assists with oral hygiene, hydration, meals and toileting.
A patient with a diagnosis of unstable angina is admitted to the intensive care unit. The nurse anticipates that which drug therapies will be prescribed? Select all that apply. Nitrates Antiplatelet therapy Anticoagulant therapy Beta-adrenergic blockers Angiotensin-converting enzyme (ACE) inhibitors
Nitrates Antiplatelet therapy Anticoagulant therapy Nitrates are the first line of drug therapy for angina because of their mechanisms of dilating peripheral blood vessels to reduce cardiac workload and dilating the coronary arteries and collateral vessels to increase blood flow to ischemic areas of the heart. Antiplatelet therapy works in different ways to inhibit platelet activation and aggregation. Anticoagulants have several different mechanisms of action to prevent the formation of fibrin and thrombin and interfere with formation of clotting factors. Beta-adrenergic blockers are commonly used in the treatment of chronic stable angina and acute coronary syndrome. ACE inhibitors are used for heart failure, tachycardia, myocardial infarction, hypertension, diabetes, and chronic kidney disease. p. 722
A patient with a history of unstable angina reports a sudden onset of retrosternal chest heaviness and tightness, fatigue, shortness of breath, and nausea. What actions should the nurse take? Select all that apply. Obtain a 12-lead ECG. Administer sublingual nitroglycerin. Place the patient in a supine position. Apply high-flow oxygen by face mask. Auscultate for a pericardial friction rub.
Obtain a 12-lead ECG. 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 intravenous (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.
When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? Oxygen, nitroglycerin, aspirin, and morphine Aspirin, nitroprusside, dopamine, and oxygen Nitroglycerin, lorazepam, oxygen, and warfarin 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.
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? Pericarditis Left-sided heart failure Ventricular aneurysm Papillary muscle dysfunction
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.
A patient with ventricular dysfunction receives a prescription for an angiotensin-converting enzyme (ACE) inhibitor. The nurse should monitor the patient for what indication of intolerance of this type of medication? Constipation Hyperactivity Persistent cough Decreased potassium levels
Persistent cough A nonproductive and persistent cough may occur in 5 percent to 25 percent 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, it is likely that the others will also. Other side effects of ACE inhibitors include drowsiness (versus hyperactivity), elevated (versus decreased) blood potassium levels, and diarrhea (versus constipation).
A patient is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse reviews the surgical plan and notes that the type of graft that will be used is prone to future stenosis and graft occlusion. Therefore the nurse anticipates postoperative use of antiplatelet and statin therapy to improve graft patency. Which type of graft will be used for the surgery? Radial artery graft Saphenous vein graft Gastroepiploic artery graft Internal mammary artery graft
Saphenous vein graft Coronary artery bypass graft surgery (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 percent, even after 10 years. A patient with high graft patency rates may not require any medication to maintain the patency of the graft.
After being identified as high risk for traditional bypass surgery, a patient is scheduled for a minimally invasive direct coronary artery bypass (MIDCAB). The nurse recognizes that which steps are involved in the procedure? Select all that apply. A robot is used to replace the mitral valve. Small incisions are made between the ribs. Cardiac catheterization is performed during the procedure. A mechanical stabilizer is placed to immobilize the operative site. A thoracoscope or robotic assistance is used to dissect the internal mammary artery from the chest.
Small incisions are made between the ribs. A mechanical stabilizer is placed to immobilize the operative site A thoracoscope or robotic assistance is used to dissect the internal mammary artery from the chest Minimally invasive direct coronary artery bypass (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.
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? Troponin Myoglobin Homocysteine Creatine kinase
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.
