chapter 36

Question 1

The nurse is developing a health teaching plan for a 60-year-old man with the following
risk factors for coronary artery disease (CAD). Which of the following risk factors should
the nurse focus on when teaching the client?
a. Family history of coronary artery disease
b. Increased risk associated with the client’s gender
c. High incidence of cardiovascular disease in older people
d. Elevation of the client’s serum low density lipoprotein (LDL) level

Answer 1

D
Because family history, gender, and age are nonmodifiable risk factors, the nurse should
focus on the client’s LDL level. Decreases in LDL will help reduce the client’s risk for
developing CAD.

Question 2

To assist the client with coronary artery disease (CAD) in making appropriate dietary
changes, which of the following nursing interventions will be most effective?
a. Instruct the client that a diet containing no saturated fat and minimal sodium will
be necessary.
b. Emphasize the increased risk for cardiac problems unless the client makes the
dietary changes.
c. Assist the client to modify favourite high-fat recipes by using polyunsaturated oils
when possible.
d. Provide the client with a list of low-sodium, low-cholesterol foods that should be
included in the diet.

Answer 2

C
Lifestyle changes are more likely to be successful when consideration is given to the
client’s values and preferences. The highest percentage of calories from fat should come
from polyunsaturated fats. Although low-sodium and low-cholesterol foods are
appropriate, providing the client with a list alone is not likely to be successful in making
dietary changes. Removing saturated fat from the diet completely is not a realistic
expectation. Telling the client about the increased risk without assisting further with
strategies for dietary change is unlikely to be successful.

Question 3

Which of the following information collected by the nurse who is admitting a client with
chest pain suggests that the pain is caused by an acute myocardial infarction?
a. The pain increases with deep breathing.
b. The pain has persisted longer than 30 minutes.
c. The pain worsens when the client raises the arms.
d. The pain is relieved after the client takes nitroglycerin.

Answer 3

B
Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial
infarction. Changes in pain that occur with raising the arms or with deep breathing are
more typical of pericarditis or musculo-skeletal pain. Stable angina is usually relieved
when the client takes nitroglycerin.

Question 4

Which of the following information given by a client admitted with chronic stable angina
will help the nurse confirm this diagnosis?
a. The client rates the pain at a level 3–5 (0–10 scale).
b. The client states that the pain “wakes me up at night.”
c. The client says that the frequency of the pain has increased over the last few
weeks.
d. The client states that the pain is resolved after taking one sublingual nitroglycerin
tablet.

Answer 4

D
Chronic stable angina is typically relieved by rest or nitroglycerin administration. The
level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or
with increased frequency is typical of unstable angina.

Question 5

The nurse is providing teaching to a client about use of sublingual nitroglycerin. Which of
the following client statements indicates that the teaching has been effective?
a. “I can expect indigestion as an adverse effect of nitroglycerin.”
b. “I can only take the nitroglycerin if I start to have chest pain.”
c. “I will call an ambulance if I still have pain 5 minutes after taking the
nitroglycerin.”
d. “I will help slow down the progress of the plaque formation by taking
nitroglycerin.”

Answer 5

C
The emergency medical services (EMS) system should be activated when chest pain or
other symptoms are not completely relieved 5 minutes after taking one nitroglycerin.
Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g.,
before intercourse). Gastric upset is not an expected adverse effect of nitroglycerin.
Nitroglycerin does not impact the underlying pathophysiology of coronary artery
atherosclerosis.

Question 6

Which of the following statements made by a client with coronary artery disease after the
nurse has completed teaching about nutritional therapy for CAD indicates that further
teaching is needed?
a. “I will switch from whole milk to 1% or nonfat milk.”
b. “I like fresh salmon and I will plan to eat it more often.”
c. “I will miss being able to eat peanut butter sandwiches.”
d. “I can have a cup of coffee with breakfast if I want one.”

Answer 6

C
Although only 30% of the daily calories should come from fats, most of the fat should
come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The
client can include peanut butter sandwiches as part of their diet. The other client comments
indicate a good understanding of diet.

Question 7

The nurse is providing teaching to a client about the use of atenolol in preventing anginal
episodes. Which of the following client statements indicate that the teaching has been
effective?
a. “It is important not to suddenly stop taking the atenolol.”
b. “Atenolol will increase the strength of my heart muscle.”
c. “I can expect to feel short of breath when taking atenolol.”
d. “Atenolol will improve the blood flow to my coronary arteries.”

Answer 7

A
Clients who have been taking b-blockers can develop intense and frequent angina if the
medication is suddenly discontinued. Atenolol decreases myocardial contractility.
Shortness of breath that occurs when taking b-blockers for angina may be due to
bronchospasm and should be reported to the health care provider. Atenolol works by
decreasing myocardial oxygen demand, not by increasing blood flow to the coronary
arteries.

Question 8

The nurse is caring for a client who has had severe chest pain for several hours and a
diagnosis of possible acute myocardial infarction. Which of the following prescribed
laboratory tests should the nurse monitor to help determine the diagnosis?
a. Homocysteine
b. C-reactive protein
c. Cardiac-specific troponin I and troponin T
d. High-density lipoprotein (HDL) cholesterol

Answer 8

C
Troponin levels increase about 3–12 hours after the onset of myocardial infarction (MI).
The other laboratory data are useful in determining the client’s risk for developing
coronary artery disease (CAD) but are not helpful in determining whether an acute MI is
in progress.

Question 9

The nurse is caring for a client with newly diagnosed Prinzmetal’s (variant) angina and has
a prescription for amlodipine. Which of the following information is accurate about
amlodipine?
a. Reduce the “fight or flight” response
b. Decrease spasm of the coronary arteries
c. Increase the force of myocardial contraction
d. Help prevent clotting in the coronary arteries

Answer 9

B
Prinzmetal’s angina is caused by coronary artery spasm. Calcium channel blockers (e.g.,
amlodipine, nifedipine) are a first-line therapy for this type of angina. Platelet inhibitors,
such as Aspirin, help prevent coronary artery thrombosis, and b-blockers decrease
sympathetic stimulation of the heart. Medications or activities that increase myocardial
contractility will increase the incidence of angina by increasing oxygen demand.

Question 10

The nurse will suspect that the client with stable angina is experiencing an adverse effect
of the prescribed metoprolol if which of the following findings are assessed?
a. The client is restless and agitated.
b. The blood pressure is 190/110 mm Hg.
c. The client complains about feeling anxious.
d. The cardiac monitor shows a heart rate of 45.

Answer 10

D
Clients taking b-adrenergic blockers should be monitored for bradycardia. Because this
category of medication inhibits the sympathetic nervous system, restlessness, agitation,
hypertension, and anxiety will not be adverse effects.

Question 11

The nurse is caring for a client with angina who has been prescribed nadolol. Which of the
following parameters should the nurse assess to determine whether the drug is effective?
a. Decreased blood pressure and apical pulse rate
b. Fewer complaints of having cold hands and feet
c. Improvement in the quality of the peripheral pulses
d. The ability to do daily activities without chest discomfort

Answer 11

D
Because the medication is ordered to improve the client’s angina, effectiveness is
indicated if the client is able to accomplish daily activities without chest pain. Blood
pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the
goal of decreased angina has been met. The noncardioselective b-blockers can cause
peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral
pulse quality or skin temperature.

Question 12

The nurse is caring for a client with a non–ST-segment-elevation myocardial infarction
(NSTEMI) who is receiving heparin. Which of the following information explains the
purpose of the heparin?
a. Platelet aggregation is enhanced by IV heparin infusion.
b. Heparin will dissolve the clot that is blocking blood flow to the heart.
c. Coronary artery plaque size and adherence are decreased with heparin.
d. Heparin will prevent the development of new clots in the coronary arteries.

Answer 12

D
Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery
thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or
enhance platelet aggregation.

Question 13

The nurse is administering IV nitroglycerin to a client with a myocardial infarction (MI).
Which of the following actions should the nurse take to evaluate the effectiveness of the
medication?
a. Check blood pressure.
b. Monitor apical pulse rate.
c. Monitor for dysrhythmias.
d. Ask about chest discomfort.

Answer 13

D
The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the
balance between myocardial oxygen supply and demand. The nurse also will monitor heart
rate and BP and observe for dysrhythmias, but these parameters will not indicate whether
the medication is effective.

Question 14

A client with ST segment elevation in several electrocardiographic (ECG) leads is
admitted to the emergency department (ED) and diagnosed as having an
ST-segment-elevation myocardial infarction (STEMI). Which of the following questions
should the nurse ask to determine whether the client is a candidate for fibrinolytic therapy?
a. “Do you take Aspirin on a daily basis?”
b. “What time did your chest pain begin?”
c. “Is there any family history of heart disease?”
d. “Can you describe the quality of your chest pain?”

Answer 14

B
Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial
infarction (MI), so the time at which the chest pain started is a major determinant of the
appropriateness of this treatment. The other information also will be needed, but it will not
be a factor in the decision about fibrinolytic therapy.

Question 15

Following an acute myocardial infarction, a client ambulates in the hospital hallway.
When the nurse is evaluating the client’s response, which of the following assessment data
would indicate that the exercise level should be decreased?
a. BP changes from 118/60 to 126/68 mm Hg.
b. Oxygen saturation drops from 100% to 98%.
c. Heart rate increases from 66 to 90 beats/minute.
d. Respiratory rate goes from 14 to 22 breaths/minute.

Answer 15

C
A change in heart rate of more than 20 beats or more indicates that the client should stop
and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen
saturation, are normal responses to exercise.

Question 16

The nurse is administering a fibrinolytic agent to a client with an acute myocardial
infarction. Which of the following assessments should cause the nurse to stop the drug
infusion?
a. Bleeding from the gums
b. Surface bleeding from the IV site
c. A decrease in level of consciousness
d. A nonsustained episode of ventricular tachycardia

Answer 16

C
The change in level of consciousness indicates that the client may be experiencing
intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums
and prolonged bleeding from IV sites are expected adverse effects of the therapy. The
nurse should address these by avoiding any further injuries, but they are not an indication
to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular
tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is
effective.

Question 17

Three days after a myocardial infarction (MI), the client develops chest pain that increases
when taking a deep breath and is relieved by leaning forward. Which of the following
actions should the nurse take next?
a. Palpate the radial pulses bilaterally.
b. Assess the feet for peripheral edema.
c. Auscultate for a pericardial friction rub.
d. Check the cardiac monitor for dysrhythmias.

Answer 17

C
The client’s symptoms are consistent with the development of pericarditis, a possible
complication of MI. The other assessments listed are not consistent with the description of
the client’s symptoms.

Question 18

The nurse is providing teaching to a client with chronic stable angina about how to use the
prescribed short-acting and long-acting nitrates. Which of the following client statements
indicates that the teaching has been effective?
a. “I will put on the nitroglycerin patch as soon as I develop any chest pain.”
b. “I will check the pulse rate in my wrist just before I take any nitroglycerin.”
c. “I will be sure to remove the nitroglycerin patch before using any sublingual
nitroglycerin.”
d. “I will stop what I am doing and sit down before I put the nitroglycerin under my
tongue.”

Answer 18

D
The client should sit down before taking the nitroglycerin to decrease cardiac workload
and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather
than to treat acute pain and can be used concurrently with sublingual nitroglycerin.
Although the nurse should check blood pressure before giving nitroglycerin, clients do not
need to check the pulse rate before taking nitrates.

Question 19

Four days after having a myocardial infarction (MI), a client who is scheduled for
discharge asks for assistance with all the daily activities, saying, “I don’t understand how
to care for myself.” Based on this information, which of the following nursing diagnoses is
appropriate?
a. Ineffective health management related to insufficient knowledge
b. Activity intolerance related to physical deconditioning
c. Ineffective denial related to ineffective coping strategies
d. Social isolation related to insufficient personal resources

Answer 19

A
The client data indicate ineffective health management related to lack of knowledge of
disease process, and care after discharge. The other nursing diagnoses may be appropriate
for some clients after an MI, but the data for this client do not support denial, activity
intolerance, or social isolation.

Question 20

The nurse is caring for a client who has survived a sudden cardiac death (SCD) event and
has no evidence of an acute myocardial infarction. Which of the following information
should the nurse teach the client?
a. That sudden cardiac death events rarely reoccur
b. About the purpose of outpatient Holter monitoring
c. How to self-administer low-molecular-weight heparin
d. To limit activities after discharge to prevent future events

Answer 20

B
Holter monitoring is used to determine whether the client is experiencing dysrhythmias
such as ventricular tachycardia during normal daily activities. SCD is likely to recur.
Heparin will not have any effect on the incidence of SCD, and SCD can occur even when
the client is resting.

Question 21

The nurse is caring for a client who is 3 days post myocardial infarction and the client
states, “I just had a little chest pain. As soon as I get out of here, I’m going for my
vacation as planned.” Which of the following responses should the nurse make?
a. “Where are you planning to go for your vacation?”
b. “What do you think caused your chest pain episode?”
c. “Sometimes plans need to change after a heart attack.”
d. “Recovery from a heart attack takes at least a few weeks.”

Answer 21

B
When the client is experiencing denial, the nurse should assist the client in testing reality
until the client has progressed beyond this step of the emotional adjustment to MI. Asking
the client about vacation plans reinforces the client’s plan, which is not appropriate in the
immediate post-MI period. Reminding the client in denial about the MI is likely to make
the client angry and lead to distrust of the nursing staff.

Question 22

The nurse is evaluating the outcomes of preoperative teaching with a client scheduled for a
coronary artery bypass graft (CABG) using the internal mammary artery. Which of the
following client statements indicates that additional teaching is needed?
a. “I will have incisions in my leg where they will remove the vein.”
b. “They will circulate my blood with a machine during the surgery.”
c. “I will need to take an Aspirin a day after the surgery to keep the graft open.”
d. “They will use an artery near my heart to bypass the area that is obstructed.”

Answer 22

A
When the internal mammary artery is used there is no need to have a saphenous vein
removed from the leg. The other statements by the client are accurate and indicate that the
teaching has been effective.

Question 23

The nurse is caring for a client who has had an acute myocardial infarction and the client
asks the nurse about when sexual intercourse can be resumed. Which of the following
responses by the nurse is best?
a. “Most clients are able to enjoy intercourse without any complications.”
b. “Sexual activity uses about as much energy as climbing two flights of stairs.”
c. “The doctor will discuss sexual intercourse when your heart is strong enough.”
d. “Holding and cuddling are good ways to maintain intimacy after a heart attack.”

Answer 23

B
Sexual activity places about as much physical stress on the cardiovascular system as
climbing two flights of stairs. The other responses do not directly address the client’s
question, or may not be accurate for this client

Question 24

The nurse is caring for a client with hyperlipidemia who has a new prescription for
colestipol. Which of the following nursing actions is best when giving the medication?
a. Administer the medication at the client’s bedtime.
b. Have the client take this medication with an Aspirin.
c. Encourage the client to take the colestipol with a sip of water.
d. Give the client’s other medications 2 hours after the colestipol.

Answer 24

D
The bile acid sequestrants interfere with the absorption of other drugs, and giving other
medications at the same time should be avoided. Taking an Aspirin concurrently with the
colestipol may increase the incidence of gastrointestinal adverse effects such as heartburn.
An increased fluid intake is encouraged for clients taking the bile acid sequestrants to
reduce the risk for constipation. For maximum effect, colestipol should be administered
with meals.

Question 25

The nurse is caring for a client who was admitted the previous day to the coronary care
unit with an acute myocardial infarction. Which of the following information should the
nurse include in the teaching plan for the client?
a. Typical emotional responses to AMI
b. When client cardiac rehabilitation will begin.
c. Discharge drugs such as Aspirin and b-blockers.
d. The pathophysiology of coronary artery disease.

Answer 25

B
Early after an AMI, the client will want to know when resumption of usual activities can
be expected. At this time, the client’s anxiety level or denial will prevent good
understanding of complex information such as coronary artery disease (CAD)
pathophysiology. Teaching about discharge medications should be done when the time for
discharge is closer. The nurse should support the client by decreasing anxiety rather than
discussing the typical emotional response to myocardial infarction (MI).

Question 26

The nurse is caring for a client who has recently started taking rosuvastatin and niacin who
reports all of these symptoms to the nurse. Which of the following finding is most
important to communicate to the health care provider?
a. Generalized muscle aches and weakness
b. Skin flushing after taking the medications
c. Dizziness when changing positions quickly
d. Nausea when taking the drugs before eating

Answer 26

A
Muscle aches and weakness may indicate myopathy and rhabdomyolysis, which have
caused acute renal failure and death in some clients who have taken the statin medications.
These symptoms indicate that the rosuvastatin may need to be discontinued. The other
symptoms are common adverse effects when taking niacin, and although the nurse should
follow up with the client, they do not indicate that a change in medication is needed.

Question 27

The nurse is admitting a client to the emergency department with severe chest pain and
gives the following list of medications taken at home to the nurse. Which of the following
medications has the most immediate implications for the client’s care?
a. Sildenafil
b. Furosemide
c. Diazepam
d. Captopril

Answer 27

A
The nurse will need to avoid giving nitrates to the client because nitrate administration is
contraindicated in clients who are using sildenafil because of the risk of sudden death
caused by vasodilation. The other home medications also should be documented and
reported to the health care provider but do not have as immediate an impact on decisions
about the client’s treatment.

Question 28

The nurse is providing teaching to a client who has a prescription for transdermal
nitroglycerin drug administration via reservoir. The client asks the nurse how often each
day will the drug be administered. Which of the following information is the basis for the
nurse’s response?
a. Every 4 hours while awake
b. Every 6 hours around the clock
c. Every 12 hours
d. Once every 24 hours

Answer 28

D
The reservoir system delivers the drug using a rate-controlled permeable membrane. The
reservoir delivery system offers the advantage of steady plasma levels within the
therapeutic range during 24 hours; thus, only one application a day is necessary.

Question 29

Which of the following causes is the most common cause for sudden cardiac death?
a. Ventricular tachycardia
b. Aortic stenosis
c. Hypertrophic cardiomyopathy
d. Angina

Answer 29

A
Acute ventricular dysrhythmias (e.g., ventricular tachycardia, ventricular fibrillation)
cause the majority of cases of SCD. Less commonly, SCD occurs because of a primary left
ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic cardiomyopathy) or
extreme slowing of the heart (bradycardia).

Question 30

Which of the following electrocardiographic (ECG) change is most important for the nurse
to communicate to the health care provider when caring for a client with chest pain?
a. Frequent premature atrial contractions (PACs)
b. Inverted P wave
c. Sinus tachycardia
d. ST segment elevation

Answer 30

D
The client is likely to be experiencing an ST-segment-elevation myocardial infarction
(STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or
fibrinolytic medications is indicated to minimize the amount of myocardial damage. The
other ECG changes also may suggest a need for therapy, but not as rapidly

Question 31

The nurse is caring for a client with acute coronary syndrome who has returned to the
coronary care unit after having percutaneous coronary intervention and the nurse obtains
these assessment data. Which of the following data indicate the need for immediate
intervention by the nurse?
a. Pedal pulses 1+
b. Heart rate 100 beats/minute
c. Blood pressure 104/56 mm Hg
d. Chest pain level 8 on a 10-point scale

Answer 31

D
The client’s chest pain indicates that restenosis of the coronary artery may be occurring
and requires immediate actions, such as administration of oxygen and nitroglycerin, by the
nurse. The other information indicates a need for ongoing assessments by the nurse.

Question 32

The nurse is admitting a client with a myocardial infarction (MI) to the intensive care unit.
Which of the following actions should the nurse carry out first?
a. Obtain the blood pressure.
b. Attach the cardiac monitor.
c. Assess the peripheral pulses.
d. Auscultate the breath sounds.

Answer 32

B
Because dysrhythmias are the most common complication of MI, the first action should be
to place the client on a cardiac monitor. The other actions also are important and should be
accomplished as quickly as possible.

Question 33

Which of the following information about a client who has been receiving fibrinolytic
therapy for an acute myocardial infarction is most important for the nurse to communicate
to the health care provider?
a. No change in the client’s chest pain
b. A large bruise at the client’s IV insertion site
c. A decrease in ST segment elevation on the electrocardiogram (ECG)
d. An increase in cardiac enzyme levels since admission

Answer 33

A
Continued chest pain suggests that the fibrinolytic therapy is not effective and that other
interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is
a possible adverse effect of fibrinolytic therapy, but it is not an indication that therapy
should be discontinued. The decrease of the ST segment elevation indicates that
fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase
in cardiac enzyme levels is expected with reperfusion and is related to the washout of
enzymes into the circulation as the blocked vessel is opened.

Question 34

The nurse obtains the following data when caring for a client who experienced an acute
myocardial infarction 2 days previously. Which of the following information is most
important to report to the health care provider?
a. The client denies ever having a heart attack.
b. The cardiac-specific troponin level is elevated.
c. The client has occasional premature atrial contractions (PACs).
d. Crackles are auscultated bilaterally in the mid-lower lobes.

Answer 34

D
The crackles indicate that the client may be developing heart failure, a possible
complication of myocardial infarction (MI). The health care provider may need to order
medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the
client. Elevation in cardiac troponin level at this time is expected. PACs are not
life-threatening dysrhythmias. Denial is a common response in the immediate period after
the MI.

Question 35

Which of the following approaches to preventing a recurrence of sudden cardiac death is
the most common?
a. Long-term Aspirin therapy
b. Implantable cardioverter-defibrillator
c. Administration of amiodarone
d. Continuous Holter monitoring

Answer 35

B
The most common approach to preventing a recurrence is the use of an implantable
cardioverter-defibrillator (ICD). Research has shown survival rates are better with an ICD
than with drug therapy alone. Drug therapy with amiodarone may be used in conjunction
with an ICD to decrease episodes of ventricular dysrhythmias. Continuous monitoring will
not prevent a recurrence. Aspirin will not prevent a recurrence of SCD.

Question 36

The nurse is admitting a client who has chest pain is to the emergency department and all
the following diagnostic tests are prescribed. Which of the following tests should the nurse
arrange to be completed first?
a. Electrocardiogram (ECG)
b. Computed tomography (CT) scan
c. Chest x-ray
d. Troponin level

Answer 36

A
The priority for the client is to determine whether an acute myocardial infarction (AMI) is
occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur
very rapidly after coronary artery occlusion. Troponin levels will increase after about 3
hours. Data from the CT scan and chest x-ray may impact the client’s care but are not
helpful in determining whether the client is experiencing a myocardial infarction (MI).

Question 37

The nurse has just received a change-of-shift report about the following four clients.
Which client should the nurse assess first?
a. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain
b. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about
the planned discharge
c. 51-year-old with unstable angina who has just returned to the unit after having a
percutaneous coronary intervention (PCI)
d. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine
(Adalat)

Answer 37

C
This client is at risk for bleeding from the arterial access site for the PCI, so the nurse
should assess the client’s blood pressure, pulse, and the access site immediately. The other
clients also should be assessed as quickly as possible, but assessment of this client has the
highest priority