Acute Coronary Syndromes

Question 1

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.

Answer 1

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

Question 2

A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating nitroglycerin 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.

Answer 2

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.

Question 3

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a 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 learning forward.
4: Obtain a 12-lead electrocardiogram

Answer 3

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 contracts 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 sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respiration. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

Question 4

A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine?
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.

Answer 4

1,4,5.
Morphine sulfate acts as an analgesic and sedative, It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing he 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.

Question 5

A client is receiving an IV infusion of heparin sodium at 1,200 units/hr. The dilution is 25,000units/500mL. How many milliliters per hour will this client receive?

Answer 5

24mL/h
First calculate how many units are in each milliliter if the medication:
25,000 units/500mL = 50 units/ 1mL
Next, calculate how many milliliters the client receives per hour:
1200 units/1 hour / 50 units/1mL
= 24 units/ 1 hour x 1mL / 1 units = 24mL/hour

Question 6

An older adult has chest pain and shortness of breath. The heath care provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do?

1: Put the tablet under the tongue until it is absorbed.
2: Swallow the tablet with 120mL of water.
3: Chew the tablet until it is dissolved.
4: Place the tablet between the cheek and gums until it disappears.

Answer 6

1.
The client is having symptoms of myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.

Question 7

The nurse has completed an assessment on a client with a decreased cardiac output. Which finding should receive the highest priority?

1: BP 110/62, atrial fibrillation with HR 82 bibasilar crackles.
2: Confusion, urine output 15mL over the last 2 hours, orthopnea.
3: SpO2 92 on 2L nasal cannula, respirations 20, 1+ pitting edema of lower extremities.
4: Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

Answer 7

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 fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable

Question 8

The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:

1: Administer atropine 0.5mg IV push.
2: Auscultate for abnormal heart sounds.
3: Prepare for transcutaneous pacing.
4: Take the client’s blood pressure.

Answer 8

4. The nurse should first assess the client’s tolerance 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 interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

Question 9

A client is admitted with a myocardial infarction and 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.

Answer 9

1.
An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

Question 10

A 60 year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count(CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first:

1: Administer the morphine.
2: Obtain a 12-lead ECG.
3: Obtain the blood work.
4: Prescribe the chest radiograph.

Answer 10

1. Although obtaining the ECG, chest radiograph, 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.

Question 11

An older adult had a myocardial infarction
(MI) 4 days ago. At 9:30 AM, the client’s blood pressure is 102/64. After reviewing the clients progress notes (see chart), the nurse should first:
1: Give a fluid challenge/bolus.
2: Notify the health care provider.
3: Assist the client to walk.
4: Administer Lasix as prescribed.

Answer 11

2. All of the 12PM assessments are signs of decreased cardiac output and can be an ominous sign in a client who has recently experienced an MI; the nurse should notify the health care provider of these changes. Cardiac output and blood pressure may continue to fall to dangerous levels, which can induce further coronary ischemia and extension of he infarct. While the client is currently hypotensive, giving a fluid challenge/bolus can precipitate increased workload on a damaged heart and extend the myocardial infarction. Exercise or walking for this client will increase both the heart rate and stroke volume, both of which will increase cardiac output, but the increased cardiac output will increase oxygen needs especially in the heart muscle and can induce further coronary ischemia and extension of the infarct. The client is hypotensive. Although the client has decreased urinary output, this is the body;s response to a decreasing cardiac output, and it is no appropriate to administer Lasix.

Question 12

When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions =, the expected outcome of the drug is for:

1: Promote hydration
2: Dissolve clots
3: Prevent kidney failure
4: Treat dysrhythmias

Answer 12

2.
Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

Question 13

The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor. The nurse should:

1: Notify the physician
2: Call the rapid response team.
3: Assess the client for changes in the rhythm
4: Administer lidocaine as prescribed

Answer 13

3.
The client is experiencing a single PVC. PVCs are characterized by a QRS of longer than 0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial infarction. The nurse should continue to monitor the client and note if the PVCs are increasing. It is not necessary to notify the physician or call the rapid response team at this point. Lidocaine is not indicated from the data on this ECG.

Question 14

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing?

1: Call for urine output less than 30mL/h for 2 consecutive hours.
2: Metoprolol (Lopressor) 5mg IV push.
3: Prepare for a pulmonary artery catheter insertion.
4: Titrate dobutamine (Dobutrex) to keep systolic BP greater than 100.

Answer 14

2.
Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock

Question 15

The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which of the following changes onf the client’s chart to the physician?

1: Urine Output (1PM 90mL/ hr; 3PM 20mL/hr).
2: Heart Rate (1PM 70/ 3PM 75).
3: Blood Pressure (1PM 110/70; 3PM 100/65).
4: Respiratory Rate (1PM 20; 3PM 26).

Answer 15

1. Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client’s chart are not as significant as the decreased urinary output.

Question 16

The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should:

1: Obtain an infusion pump for the medication.
2: Take the blood pressure every 4 hours.
3: Monitor urine output hourly.
4: Obtain serum potassium levels daily.

Answer 16

1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. 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 nitroglycerin infusion.

Question 17

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following in which order from first to last?

1: Obtain a history of which drugs the client has used recently.
2: Administer the prescribed dose of morphine.
3: Position electrodes on the chest.
4: Take vital signs.

Answer 17

3. Position electrodes on the chest.
4. Take vital signs.
5. Administer the prescribed dose of morphine.
6. Obtain a history of which drugs the client has used recently.
   The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client’s heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client’s drug use.

Question 18

The nurse is assessing a cline who has had a myocardial infarction. The nurse identifies the rhythm as:

1: Atrial fibrillation
2: Ventricular tachycardia
3: Premature ventricular contractions
4: Sinus tachycardia

Answer 18

4.
Sinus tachycardia is characterized by normal conduction and regular rhythm, but with a rate exceeding 100bpm. A P wave precedes each QRS, and the QRS is usually normal.

Question 19

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and oxygen at 2L/min. The nurse’s first course of action should be to:

1: Increase the IV infusion rate.
2: Notify the physician promptly.
3: Increase the oxygen concentration.
4: Administer a prescribed analgesic.

Answer 19

2.
PVCs are often precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considers dangerous, but if PVCs occur at a rate greater than five to six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse’s first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

Question 20

Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client:

1: Continues to have severe chest pain.
2: Can identify risk factors for MI.
3: Participates in a cardiac rehabilitation walking program.
4: Can perform personal self-care activities without pain.

Answer 20

4.
By day 2 of hospitalization after an MI clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization 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.

Question 21

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide?

1: Increased blood pressure.
2: Increased urine output.
3: Decreased pain.
4: Decreased premature ventricular contractions.

Answer 21

2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

Question 22

The nurse is preparing to measure central venous pressure (CVP) Where do you level the transducer.

Answer 22

Correct location: The zero point on the CVP transducer needs to be at the level of the right atrium. The right atrium is locate at the midaxillary line at the fourth intercostal space. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest. A second imaginary line is drawn horizontally at the level of midpoint between the anterior and posterior surfaces of the chest. The phlebostatic axis is located at the intersection of points A and B.

Question 23

A client has a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?

1: Cardiac output.
2: Right atrial blood flow.
3: Left end-diastolic pressure.
4: Cardiac index.

Answer 23

3.
When wedged, the catheter is “pointing” indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the ballon is wedged, the catheter reads the pressure in front of the ballon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client’s cardiac output by the client’s body surface area, and is considered a more accurate reflection of the individual client’s cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.

Question 24

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to:

1: Prepare the client for ambulation.
2: Promote urinary and intestinal elimination.
3: Prevent thrombophlebitis and blood clot formation.
4: Decrease the likelihood of pressure ulcer formation.

Answer 24

3.
Encouraging the client to move the legs while in bed is a preventative strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.

Question 25

Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?

1: Liquids are desired.
2: Small, easily digested meals.
3: Three regular meals per day.
4: Nothing by mouth

Answer 25

2.
Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestation of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only restricted to nothing by mouth unless their condition is very unstable.

Question 26

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply.

1: The client should report unexpected bleeding or bleeding that lasts a long time.
2: The client should always take Plavix with food.
3: The client may bruise more easily and may experience bleeding gums.
4: Plavix works by preventing platelets from sticking together and forming a clot.
5: The client should drink a glass of water after taking Plavix.

Answer 26

1,3,4.
Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

Question 27

Which client is at greatest risk for coronary artery disease?

1: A 32-year-old female with mitral valve prolapse 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.

Answer 27

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

Question 28

A middle-aged adult with a family history of CAD has the following fasting blood laboratory test results: total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; triglycerides 148; blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why it is necessary to take these medication. Which is the best response by the nurse?

1: “The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.”
2: “The triglycerides are elevated and will not return to normal without these medications.”
3: “The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by medications prescribed.”
4: “Your blood sugar is elevated and these medications will reduce the risk of type 2 diabetes.”

Answer 28

3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAS. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.

Question 29

The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective?

1: Decreased chest pain.
2: Increased blood pressure.
3: Decreased blood pressure.
4: Decreased heart rate.

Answer 29

1. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for he heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerin, it is only secondary and not related to the angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

Question 30

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 risk factor 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.

Answer 30

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 effective as reward.

Question 31

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: Recascularize the blocked coronary artery.

Answer 31

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

Question 32

After the administration of t-PA, the nurse should:

1: Observe the client for chest pain.
2: Monitor for fever.
3: Review the 12-lead electrocardiogram (ECG)
4: Auscultate breath sounds

Answer 32

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 times are essential to detect complications. Administration of t-PA should not cause fever.

Question 33

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

Answer 33

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 administration of t-PA. Seizures an hypothermia are not generally associated with reperfusion of the cardiac tissue.

Question 34

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contraindications to administering the drug?

1: Age greater than 60 years.
2: History of cerebral hemorrhage.
3: History of heart failure.
4: Cigarette smoking

Answer 34

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.

Question 35

A client has driven himself to the emergency department, He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2L.min per nasal cannula. The nurse’s nest action should be to:

1: Call for he physician
2: Start an IV infusion
3: Obtain a portal chest radiograph
4: Draw blood for laboratory studies

Answer 35

2.
Advanced cardiac life support recommends that at least one or two IV lines to be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to stating the IV line.

Question 36

Crackles heard on lung auscultation indicate which of the following?

1: Cyanosis
2: Bronchospasm
3: Airway narrowing
4: Fluid-filled alveoli

Answer 36

4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

Question 37

A 68-year-old 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.

Answer 37

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.

Question 38

The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following?

1: Left ventricle atrophy
2: Irregular heartbeats
3: Peripheral vascular occlusion
4: Pacemaker placement

Answer 38

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 cardiac 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. Irregular heartbeats are generally not associated with an older sedentary adult’s lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

Question 39

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?

1: Climb the steps 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 after climbing the stairs

Answer 39

3.
Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs 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.

Question 40

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best?

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

Answer 40

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.

Question 41

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to the physician>

1: A change in the pattern of chest pain
2: Pain during sexual activity
3: Pain during an argument
4: Pain during or after a physical activity.

Answer 41

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 unexpected, 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.

Question 42

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 situation to:

1: Open and dilate block coronary arteries.
2: Assess the extent of arterial blockage.
3: Bypass obstructed vessels.
4: Assess the functional adequacy of the valves and heart muscle.

Answer 42

2.
Cardiac catheterization is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.

Question 43

The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:

1: Minimizing dyspnea
2: Maintaining adequate blood pressure control
3: Decreasing myocardial contractility
4: Preventing fluid volume deficit

Answer 43

4. Because the contrast medium use in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.

Question 44

Which of the following is not a risk factor for the development of atherosclerosis?

1: Family history of early heart attack
2: Late onset puberty
3: Total blood cholesterol level greater than 220mg/dL
4: Elevated fasting blood glucose concentration

Answer 44

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

Question 45

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg 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

Answer 45

3,
Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessel may also increase blood flow to he ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

Question 46

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 nitroglycerin with a few glasses of water will reduce the problem
4: The client should lie in a supine position to alleviate the headache

Answer 46

1. Headache is a common side effect of nitroglycerin 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 flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

Question 47

How should the nurse instruct the client with unstable angina to use sublingual nitroglycerine tablets when chest pain occurs? “Sit dow and then

1: take one tablet every 2 to 5 minutes until the pain stops.”
2: take one tablet and rest for 15 minutes.”
3: take one tablet, then if the pain persists take additional two tablets in 5 minutes. Call the physician if pain persists after 15 minutes.”
4: take one tablet. If pain persists after 5 minutes call 911.”

Answer 47

4.
The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some physicians may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait within 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the physician.

Question 48

A client with angina is 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

Answer 48

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.

Question 49

The nurse is developing a teaching plan for a client who will be starting a prescription for Zocor (simvastatin) 40mg/day . The nurse should instruct the client about which of the following? Select all that apply,

1: “Take once a day in the morning”
2: “If you miss a dose, take it when you remember it, but do not double the dose if you do not remember to take it until it is time for your next dose”
3: “Limit greens such as lettuce in the diet to prevent bleeding.”
4: “Be sure to take the pill with food.”
5: “Report muscle pain or tenderness to your health care provider.”
6: “Continue to follow a diet that is low in saturated fats.”

Answer 49

2,5,6.
Zocor (Simvastatin) is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take Zocor in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking Coumadin), but the nurse should instruct the client to avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the health care provider.