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A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
a. Assess the client's pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best?
a. "The t-PA didn't dissolve the entire coronary clot."
b. "The heparin keeps that artery from getting blocked again."
c. "Heparin keeps the blood as thin as possible for a longer time."
d. "The heparin prevents a stroke from occurring as the t-PA wears off."
After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.
This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best?
a. "Continue to educate the client on possible healthy changes."
b. "Emphasize complications that can occur with noncompliance."
c. "Tell the client that denial is normal and will soon go away."
d. "You need to make sure the client understands this illness."
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
a. Level the transducer at the phlebostatic axis.
b. Lay the client in the supine position.
c. Prepare to administer diuretics.
d. Prepare to administer a fluid bolus.
Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?
a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends.
b. Ensure the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler's position.
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client's stress levels.
d. Tell the client that anxiety is common and that you can help.
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
c. "Sleep near your spouse in case of emergency."
d. "Why would you move into the guest room?"
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider.
Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?
a. Assess for any hemodynamic effects of the rhythm.
b. Prepare to administer antidysrhythmic medication.
c. Notify the provider or call the Rapid Response Team.
d. Turn the alarms off on the cardiac monitor.
Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.
The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important?
a. Assess vital signs.
b. Don a mask and gown.
c. Gather needed supplies.
d. Perform hand hygiene.
To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.
A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first?
a. Assess the insertion site.
b. Change the client's sheets.
c. Put on a pair of gloves.
d. Assess blood pressure.
For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
c. Client who is 1 day post percutaneous coronary intervention, going home this morning
d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.
A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?
a. "Fish oil is contraindicated with most drugs for CAD."
b. "The best source is fish, but pills have benefits too."
c. "There is no evidence to support fish oil use with CAD."
d. "You can reverse CAD totally with diet and supplements."
Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes?
a. Obtain an electrocardiogram (ECG) now and in the morning.
b. Give the client an aspirin.
c. Notify the Rapid Response Team.
d. Prepare to administer thrombolytics.
The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.
A nurse is caring for four clients. Which client should the nurse assess first?
a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, potassium 4.2 mEq/L
The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort?
a. Allow family members to remain at the bedside.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the client's favorite channel.
d. Speak loudly to the client in case of hearing problems.
Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots.
If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.
A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?
a. Dirty carpets in need of vacuuming
b. Expired food in the refrigerator
c. Old medications in the kitchen
d. Several cats present in the home
Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
b. Monitor the pedal pulses.
c. Monitor the client's vital signs.
d. Obtain consent for a central line.
Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM)
The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).
The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse?
a. "It constricts vessels, improving blood flow."
b. "It dilates vessels, which lessens the work of the heart."
c. "It increases the force of the heart's contractions."
d. "It slows the heart rate down for better filling."
A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.
A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate?
(Click the media button to hear the audio clip.)
a. Assess for further chest pain.
b. Call the Rapid Response Team.
c. Have the client sit upright.
d. Listen to the client's lung sounds.
The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below:
What action by the nurse is most important?
a. Assess the client's blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication.
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the client's hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)
ANS: B, C, D, E
Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol.
ANS: A, C, E
The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
ANS: A, B, D, E
The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.
A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing.
ANS: B, D, E
Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.)
a. Advanced age
c. Ethnic background
d. Medication use
ANS: A, B, C, E
Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.
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