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Chapter 38: Care of Patients with Acute Coronary Syndromes
Terms in this set (56)
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?
op the infusion and call the provider.
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage.
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?
"The heparin keeps that artery from getting blocked again."
After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding.
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?
Allow continued bathroom privileges.
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.
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?
"Continue to educate the client on possible healthy changes."
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.
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?
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.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?
Ensure the balloon does not remain wedged.
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP 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?
Assess the client for bleeding.
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
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?
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.
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?
"Do you have any concerns about sexuality?"
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
Maintain airway patency.
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
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm.
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 nurse is preparing to change a client's sternal dressing. What action by the nurse is most important?
Perform hand hygiene.
To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a 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?
Put on a pair of gloves.
For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure.
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
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.
A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?
"The best source is fish, but pills have benefits too."
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.
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?
Give the client an aspirin.
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 nurse is caring for four clients. Which client should the nurse assess first?
Client who is 1 hour post angioplasty, has tongue swelling and anxiety
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.
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?
Allow family members to remain at the bedside.
Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up).
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?
Notify the provider immediately.
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.
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?
Expired food in the refrigerator
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.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
Assess the IV site hourly.
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.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
Poor peripheral pulses and cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately.
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?
1630 (4:30 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?
"It increases the force of the heart's contractions."
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.)
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.
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?
Assess the client's blood pressure and level of consciousness.
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.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)
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.)
Assist the client to the chair for meals and to the bathroom.
Ensure the client wears TED hose or sequential compression devices.
Take and record a full set of vital signs per hospital protocol.
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.)
Accompanied by shortness of breath
Feelings of fear or anxiety
No relief from taking nitroglycerin
Pain occurs without known cause
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.)
Assist the client into a position of comfort in bed.
Provide complementary therapies such as music.
Remind the client to splint the incision when coughing.
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.)
A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching?
"This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year."
Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year.
The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure?
Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure.
The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize?
Do not smoke or chew tobacco.
Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen.
To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests?
CK-MB and troponin
CK-MB and troponin are the cardiac markers used to determine whether MI has occurred
Prompt pain management with myocardial infarction is essential for which reason?
Pain relief improves oxygen supply and decreases oxygen demand.
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign?
During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest?
Placing a chair in the shower for independent hygiene
Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.
The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed?
Respiratory rate 28 breaths/min
Tachypnea and tachycardia reflect activity intolerance; activity should be terminated.
The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first?
Client with third-degree heart block on the monitor
third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first.
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure
Crackles in the lung fields
A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct?
"These arteries remain open longer.
A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon?
Chest tube drainage 175 mL last hour
Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL/hr to the surgeon
The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first?
Monitor for dysrhythmias.
During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response?
"Where might you be able to walk?"
An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take?
Assess pulmonary artery wedge pressure (PAWP).
The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI?
Substernal chest pressure relieved only by opioids Correct
A client comes to the emergency department with chest discomfort. Which action does the nurse perform first?
Obtains the client's description of the chest discomfort
Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching?
"My angina will be gone for good."
After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first?
The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea
An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN?
A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today
Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.)
Increasing age Correct
Family history Correct
Abdominal obesity Correct
The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (Select all that apply.)
Truncal obesity Correct
Glucose intolerance Correct
Client taking losartan (Cozaar) Correct
Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.)
Extreme fatigue Correct
When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? (Select all that apply.)
Morphine sulfate Correct
The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.)
Cool, diaphoretic skin Correct
Crackles in the lung fields Correct
Anxiety and restlessness Correct
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