Test 2

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: 1. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. 2. Nitroglycerin should be avoided if the client is experiencing this serious side effect. 3. Taking the nitroglycerin with a few glasses of water will reduce the problem. 4. The client should lie in a supine position to alleviate the headache.

1. Headache is a common side effect of nitro-glycerin that can be alleviated with aspirin, acetaminophen or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying fl at will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

The physician orders continuous I.V. nitro-glycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following? 1. Obtaining an infusion pump for the medication. 2. Monitoring blood pressure every 4 hours. 3. Monitoring urine output hourly. 4. Obtaining serum potassium levels daily.

1. I.V. nitroglycerin infusion requires an infusion pump for precise control of the medica-tion. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: 1. Left ventricular atrophy. 2. Irregular heartbeats. 3. Peripheral vascular occlusion. 4. Pacemaker placement.

1. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased car-diac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process.

The major goal of therapy for a client with heart failure and pulmonary edema should be to: 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.

1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmo-nary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respi-ratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12 Lead electrocardiogram.

1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle con-tracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

A 69-year-old female has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should the nurse assess first? 1. Blood pressure. 2. Skin breakdown. 3. Serum potassium level. 4. Urine output

1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.

1. The ankle edema suggests fl uid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: 1. Open and dilate blocked coronary arteries. 2. Assess the extent of arterial blockage. 3. Bypass obstructed vessels. 4. Assess the functional adequacy of the valves and heart muscle.

2. Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results.

A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? 1. Dilated coronary arteries. 2. Increased myocardial contractility. 3. Decreased cardiac arrhythmias. 4. Decreased electrical conductivity in the heart.

2. Digoxin is a cardiac glycoside with posi-tive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.

A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition? 1. Hyperkalemia. 2. Digoxin toxicity. 3. Fluid deficit. 4. Pulmonary edema.

2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fl uid defi cit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxic-ity. Pulmonary edema is manifested by dyspnea and coughing.

Which of the following is not a risk factor for the development of atherosclerosis? 1. Family history of early heart attack. 2. Late onset of puberty. 3. Total blood cholesterol level greater than 220 mg/dL. 4. Elevated fasting blood glucose concentration.

2. Late onset of puberty is not generally con-sidered to be a risk factor for the development of ath-erosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gen-der, diabetes mellitus, obesity, and physical inactivity.

A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitro-glycerin drip? 1. Serum potassium is 3.5 mEq/L. 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.

2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

The nurse should teach the client that signs of digoxin toxicity include which of the following? 1. Rash over the chest and back. 2. Increased appetite. 3. Visual disturbances such as seeing yellow spots 4. Elevated BP.

3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fi brilla-tion or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.

A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: 1. Decrease circulatory overload. 2. Improve the myocardial workload. 3. Prevent thrombus formation. 4. Regulate cardiac rhythm.

3. Coumadin is an anticoagulant, which is used in the treatment of atrial fi brillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.

The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following? 1. Maintaining a high-fiber diet. 2. Walking 2 miles every day. 3. Obtaining daily weights at the same time each day. 4. Remaining sedentary for most of the day.

3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lb. or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life-threatening.

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk

3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia.

1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administra-tion of t-PA. Seizures and hypothermia are not gener-ally associated with reperfusion of the cardiac tissue.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? 1. A change in the pattern of her pain. 2. Pain during sexual activity. 3. Pain during an argument with her husband. 4. Pain during or after an activity such as lawn-mowing.

1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unex-pected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn-mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking.

2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.

The nurse has completed an assessment on a client with a decreased cardiac output. Which fi nd-ings should receive the highest priority? 1. BP 110/62, atrial fi brillation with HR 82, bibasilar crackles. 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. 3. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fi brillation there is a loss of atrial kick, but the blood pressure and heart rate are stable.

Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth.

2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated.

If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the old behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior.

3. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

In which of the following positions should the nurse place a client with suspected heart failure? 1. Semi-sitting (low Fowler's position). 2. Lying on the right side (Sims' position). 3. Sitting almost upright (high Fowler's position). 4. Lying on the back with the head lowered (Trendelenburg's position).

3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial work-load. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg's position.

The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a: 1. Low sodium level. 2. High glucose level. 3. High calcium level. 4. Low potassium level.

4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excit-ability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.

When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by: 1. Left ventricular overload. 2. Impending circulatory collapse. 3. Extracellular electrolyte imbalances. 4. Insufficient oxygen reaching the heart muscle.

4. An MI interferes with or blocks blood circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina.

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 1. Cancer. 2. Hypertension. 3. Liver disease. 4. Myocardial damage.

4. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction. Myoglobin does not help diagnose cancer, hypertension, or liver disease.

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.

4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when adminis-tered within the fi rst 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhyth-mias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.

The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? 1. A 32-year-old female with mitral valve pro-lapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158. 3. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor). 4. A 65-year-old female who is obese with an LDL of 188.

4. The woman who is 65 years old, over-weight and has an elevated LDL is at greatest risk. Total cholesterol > 200, LDL > 100, HDL < 40 in men, HDL < 50 in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medica-tion to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity, and high LDL cholesterol places this client at greatest risk.

Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable? 1. Evaluate the lung sounds. 2. Help the client identify risk factors for CAD. 3. Provide teaching on a 2 g sodium diet. 4. Record the intake and output.

4. Unlicensed personnel are able to measure and record intake and output. The nurse is respon-sible for client teaching, physical assessments, and evaluating the information collected on the client.

Which of the following is an expected out-come for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: 1. Has severe chest pain. 2. Can identify risk factors for MI. 3. Agrees to participate in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities with-out pain.

. By day 2 of hospitalization after an MI, cli-ents are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitaliza-tion may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.

Which of the following nursing diagnoses would be appropriate for a client with systolic heart failure? Select all that apply. 1. Ineffective peripheral tissue perfusion related to a decreased stroke volume. 2. Activity intolerance related to impaired gas exchange and perfusion. 3. Dyspnea related to pulmonary congestion and impaired gas exchange. 4. Decreased cardiac output related to impaired cardiac filling. 5. Impaired renal perfusion related to a decreased cardiac output.

1, 2, 3, 5. A decrease in cardiac output occurs from a decreased stroke volume with impaired contractility in systolic heart failure. This impairs peripheral and renal perfusion. The impaired perfusion and impaired oxygenation cause the symptoms of activity intolerance. The decreased systolic function causes an increase in residual volume and pressure in the left ventricle. A retrograde buildup of pressure from the left ventricle to left atria increases hydrostatic pressure in the pulmonary vasculature. This causes a leakage of fluid into the interstitial tissue of the lungs resulting in pulmonary symptoms. With diastolic heart failure, there is impaired ventricular filling due to a rigid ventricle and reduced ventricular relaxation.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. 1. Becoming increasingly short of breath at rest. 2. Weight gain of 2 lb or more in 1 day. 3. High intake of sodium for breakfast. 4. Having to sleep sitting up in a reclining chair. 5. Weight loss of 2 lb in 1 day.

1, 2, 4. The client stating that he would call the physician with increasing shortness of breath, weight gain over 2 lb in 1 day, and having to sleep sitting up, indicates that he has understood the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tab-lets, 0.3 mg given sublingually. This drug's principal effects are produced by: 1. Antispasmodic effects on the pericardium. 2. Causing an increased myocardial oxygen demand. 3. Vasodilation of peripheral vasculature. 4. Improved conductivity in the myocardium.

3. Nitroglycerin produces peripheral vasodi-lation, which reduces myocardial oxygen consump-tion and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood fl ow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective? 1. 90 percent of clients have not gained weight. 2. 75 percent of the clients viewed the educational DVD. 3. 80 percent of the clients reported that they are taking their medications. 4. 5 percent of the clients required hospitalization in the last 90 days.

4. The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission, thus interventions, such as monitoring and teaching appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material and continue to take their medication, the primary indicator of effectiveness of the program is the lack of re-hospitalization.

When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to: 1. Help keep him well hydrated. 2. Dissolve clots that he may have. 3. Prevent kidney failure. 4. Treat potential cardiac arrhythmias

Thrombolytic drugs are administered within the fi rst 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply. 1. Ventricular hypertrophy. 2. Parasympathetic nervous stimulation. 3. Renin-angiotensin-aldosterone system. 4. Jugular venous distention. 5. Sympathetic nervous stimulation

1, 3, 5. When the heart begins to fail, the body activates three major compensatory systems: ventricular hypertrophy, the renin-angiotensin- aldosterone system, and sympathetic nervous stimulation. Parasympathetic stimulation and jugular venous distention are not compensatory mechanisms associated with heart failure.

A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.

1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen con-sumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

After the administration of t-PA, the assessment priority is to: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. 4. Monitor breath sounds.

1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between his cheek and gums.

3. The client is having symptoms of a myo-cardial infarction. The fi rst action is to prevent platelet formation and block prostaglandin synthe-sis. The nitroglycerin tablet will be absorbed fastest if the client chews the tablet.

A client with angina has been taking nifedipine. The nurse should teach the client to: 1. Monitor blood pressure monthly. 2. Perform daily weights. 3. Inspect gums daily. 4. Limit intake of green leafy vegetables.

3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? 1. Take one tablet every 2 to 5 minutes until the pain stops. 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. 3. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets. 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.

3. The correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes.

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.

4. Nursing management for a client with a myocardial infarction should focus on pain manage-ment and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse should suspect atrial fibrillation when palpation of the radial pulse reveals: 1. Two regular beats followed by one irregular beat. 2. An irregular pulse rhythm. 3. Pulse rate below 60 bpm. 4. A weak, thready pulse.

2. Characteristics of atrial fi brillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no defi nite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.

During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem? 1. Visit her friend early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down once she reaches the friend's apartment.

3. Nitroglycerin may be used prophylacti-cally before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: 1. Administer Atropine 0.5 mg I.V. push. 2. Auscultate for abnormal heart sounds. 3. Prepare for transcutaneous pacing. 4. Take the client's blood pressure.

4. The nurse should fi rst assess the client's tol-erance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interven-tions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myo-cardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Order the chest radiograph

1. Although obtaining the ECG, chest radio-graph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.

1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles.

A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.

1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.