Chapter 34: Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 34: Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome

Test Bank

MULTIPLE CHOICE

1. When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the

a.

family history of coronary artery disease.

b.

increased risk associated with the patients gender.

c.

high incidence of cardiovascular disease in older people.

d.

elevation of the patients serum low density lipoprotein (LDL) level.

ANS: D

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

DIF: Cognitive Level: Application REF: 767 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

2. To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective?

a.

Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.

b.

Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.

c.

Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible.

d.

Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

ANS: C

Lifestyle changes are more likely to be successful when consideration is given to the patients values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient 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; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

DIF: Cognitive Level: Application REF: 767-768

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)?

a.

The pain increases with deep breathing.

b.

The pain has persisted longer than 30 minutes.

c.

The pain worsens when the patient raises the arms.

d.

The pain is relieved after the patient takes nitroglycerin.

ANS: B

Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin.

DIF: Cognitive Level: Application REF: 779

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

a.

The patient rates the pain at a level 3 to 5 (0 to 10 scale).

b.

The patient states that the pain wakes me up at night.

c.

The patient says that the frequency of the pain has increased over the last few weeks.

d.

The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

ANS: 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.

DIF: Cognitive Level: Comprehension REF: 771-776

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

a.

I can expect indigestion as a side 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.

ANS: 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 side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

DIF: Cognitive Level: Application REF: 775-776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

6. Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet 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.

ANS: C

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

DIF: Cognitive Level: Application REF: 768 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

7. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates 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.

ANS: A

Patients who have been taking b-blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) 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.

DIF: Cognitive Level: Application REF: 775 | 776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

8. A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI?

a.

Homocysteine

b.

C-reactive protein

c.

Cardiac-specific troponin I and troponin T

d.

High-density lipoprotein (HDL) cholesterol

ANS: C

Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patients risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

DIF: Cognitive Level: Comprehension REF: 780-781

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will

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.

ANS: B

Prinzmetals angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) 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.

DIF: Cognitive Level: Application REF: 776

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if

a.

the patient is restless and agitated.

b.

the blood pressure is 190/110 mm Hg.

c.

the patient complains about feeling anxious.

d.

the cardiac monitor shows a heart rate of 45.

ANS: D

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

DIF: Cognitive Level: Application REF: 776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

11. Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for

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.

ANS: D

Because the medication is ordered to improve the patients angina, effectiveness is indicated if the patient 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.

DIF: Cognitive Level: Application REF: 776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

12. A patient with a nonST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is 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.

ANS: 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.

DIF: Cognitive Level: Comprehension REF: 775

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will 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.

ANS: 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.

DIF: Cognitive Level: Application REF: 784-785 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

14. A patient 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 question should the nurse ask to determine whether the patient 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?

ANS: 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.

DIF: Cognitive Level: Application REF: 782-783

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response, which of these 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.

ANS: C

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

DIF: Cognitive Level: Application REF: 792 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

16. During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences

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.

ANS: C

The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side 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.

DIF: Cognitive Level: Application REF: 783-784 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

17. Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action 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.

ANS: C

The patients 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 patients symptoms.

DIF: Cognitive Level: Application REF: 780

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient 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.

ANS: D

The patient 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, patients do not need to check the pulse rate before taking nitrates.

DIF: Cognitive Level: Application REF: 775-776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

19. Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate?

a.

Ineffective coping related to anxiety

b.

Activity intolerance related to weakness

c.

Denial related to lack of acceptance of the MI

d.

Social isolation related to lack of support system

ANS: A

The patient data indicates that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation.

DIF: Cognitive Level: Application REF: 788-789 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Psychosocial Integrity

20. When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient

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.

ANS: B

Holter monitoring is used to determine whether the patient 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 patient is resting.

DIF: Cognitive Level: Application REF: 793-794 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

21. A few days after experiencing a myocardial infarction (MI), the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my vacation as planned. Which response 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.

ANS: B

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

DIF: Cognitive Level: Application REF: 788-789

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says,

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.

ANS: 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 patient are accurate and indicate that the teaching has been effective.

DIF: Cognitive Level: Application REF: 783-784 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

23. A patient who has had an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best?

a.

Most patients 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.

ANS: 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 patients question, or may not be accurate for this patient.

DIF: Cognitive Level: Application REF: 792

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when giving the medication?

a.

Administer the medication at the patients bedtime.

b.

Have the patient take this medication with an aspirin.

c.

Encourage the patient to take the colesevelam with a sip of water.

d.

Give the patients other medications 2 hours after the colesevelam.

ANS: 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 colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

DIF: Cognitive Level: Application REF: 770-771

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about

a.

typical emotional responses to AMI.

b.

when patient cardiac rehabilitation will begin.

c.

discharge drugs such as aspirin and b-blockers.

d.

the pathophysiology of coronary artery disease.

ANS: B

Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patients 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 patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI).

DIF: Cognitive Level: Application REF: 788-789 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

26. A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider?

a.

Generalized muscle aches and pains

b.

Skin flushing after taking the medications

c.

Dizziness when changing positions quickly

d.

Nausea when taking the drugs before eating

ANS: A

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

DIF: Cognitive Level: Application REF: 768-770

OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

27. A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patients care?

a.

sildenafil (Viagra)

b.

furosemide (Lasix)

c.

diazepam (Valium)

d.

captopril (Capoten)

ANS: A

The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients 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 patients treatment.

DIF: Cognitive Level: Application REF: 773 | 775-776

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

28. Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician?

a.

Complaints of incisional chest pain

b.

Crackles audible at both lung bases

c.

Pallor and weakness of the right hand

d.

Redness on either side of the chest incision

ANS: C

The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

DIF: Cognitive Level: Application REF: 788

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN?

a.

Perform the initial assessment of the catheter insertion site.

b.

Teach the patient about the usual postprocedure plan of care.

c.

Check the rate on the infusion pump used to administer heparin.

d.

Administer the scheduled aspirin and lipid-lowering medication.

ANS: D

Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and administration of intravenous anticoagulant medications should be done by the RN.

DIF: Cognitive Level: Application REF: 793

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

30. Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain?

a.

Frequent premature atrial contractions (PACs)

b.

Inverted P wave

c.

Sinus tachycardia

d.

ST segment elevation

ANS: D

The patient 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.

DIF: Cognitive Level: Application REF: 780-781

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse?

a.

Pedal pulses 1+

b.

Heart rate 100 beats/min

c.

Blood pressure 104/56 mm Hg

d.

Chest pain level 8 on a 10-point scale

ANS: D

The patients 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.

DIF: Cognitive Level: Application REF: 781-782

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient?

a.

Acute pain related to myocardial ischemia

b.

Anxiety related to perceived threat of death

c.

Decreased cardiac output related to cardiogenic shock

d.

Activity intolerance related to decreased cardiac output

ANS: C

All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart).

DIF: Cognitive Level: Application REF: 786

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

33. When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action 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.

ANS: B

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

DIF: Cognitive Level: Application REF: 779-780 | 787-788

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider?

a.

No change in the patients chest pain

b.

A large bruise at the patients IV insertion site

c.

A decrease in ST segment elevation on the electrocardiogram (ECG)

d.

An increase in cardiac enzyme levels since admission

ANS: 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 side 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.

DIF: Cognitive Level: Application REF: 782-783

OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

35. The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider?

a.

The patient denies ever having a heart attack.

b.

The cardiac-specific troponin level is elevated.

c.

The patient has occasional premature atrial contractions (PACs).

d.

Crackles are auscultated bilaterally in the mid-lower lobes.

ANS: D

The crackles indicate that the patient 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 patient. 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.

DIF: Cognitive Level: Application REF: 779-780

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

36. Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN?

a.

Evaluating the patients response to ambulation in the hallway

b.

Completing the documentation for a home health nurse referral

c.

Educating the patient about the pathophysiology of heart disease

d.

Reinforcing teaching about the purpose of prescribed medications

ANS: D

LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice.

DIF: Cognitive Level: Application REF: 789-793

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

37. A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first?

a.

Electrocardiogram (ECG)

b.

Computed tomography (CT) scan

c.

Chest x-ray

d.

Troponin level

ANS: A

The priority for the patient 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 patients care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI).

DIF: Cognitive Level: Application REF: 782

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

38. The nurse has just received change-of-shift report about the following four patients. Which patient 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 (Procardia)

ANS: C

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

DIF: Cognitive Level: Analysis REF: 781-782

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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