Chapter 6 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 6

Question 1

Type: MCSA

A patient says, Ive never heard of an acute coronary syndrome. Please explain what happened to me. The nurse should respond, Acute coronary syndrome is:

1. Another name for a myocardial infarction (MI) or heart attack.

2. A group of disorders that result in insufficient oxygen supply to the heart.

3. The second leading cause of death in the United States.

4. A type of abnormal heart rhythm.

Correct Answer: 2

Rationale 1: An MI/heart attack is only one of the disorders that falls under this group of disorders. An MI includes tissue necrosis from arterial obstruction.

Rationale 2: Acute coronary syndrome (ACS) is an inclusive term for conditions that cause chest pain due to insufficient blood supply to the heart muscle.

Rationale 3: ACS is the leading cause of death in United States.

Rationale 4: ACS is not a type of abnormal heart rhythm.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-1: Explain acute coronary syndrome.

Question 2

Type: MCSA

The nurse is teaching a patient about acute coronary syndrome. What will the nurse teach that describes the progression of events in this disorder?

1. A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS.

2. When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS.

3. The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS.

4. Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS.

Correct Answer: 3

Rationale 1: The formation of fibrin along the area of ruptured plaque will stabilize the thrombi and fully occlude the coronary vessel.

Rationale 2: When occlusion occurs, ST elevation occurs; necrosis and ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased contractility, causing decreased cardiac output.

Rationale 3: Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest.

Rationale 4: The buildup of plaque takes a longer period and will not give immediate symptoms of an MI. Stable angina occurs in a predictable manner, because there is gradual reduction of the vessel lumen size and other vessels may compensate for this minor hypoxia until the vessel is completely occluded.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-1: Explain acute coronary syndrome.

Question 3

Type: MCSA

A nurse is discussing management of hypertension with a patient. Which patient statement indicates that additional teaching about the relationship between hypertension and acute coronary syndrome (ACS) is needed?

1. My high blood pressure has no relationship to the severity of heart disease or its outcomes.

2. Because Im over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk.

3. High blood pressure will increase my bodys need for oxygen and increase my hearts workload.

4. Controlling my blood pressure will decrease my risk of having a heart attack to some degree.

Correct Answer: 1

Rationale 1: The higher the hypertension rates, the greater the severity of ACS. There is a direct correlation between the two.

Rationale 2: This statement does not indicate that more teaching is required.

Rationale 3: This statement does not indicate that more teaching is required.

Rationale 4: This statement does not indicate that more teaching is required.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-1: Explain acute coronary syndrome.

Question 4

Type: MCSA

Which statement explaining the relationship of body weight to acute coronary syndrome (ACS) should the nurse include when presenting a healthy heart program to a community group?

1. Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS.

2. Extra weight can lead to diabetes insipidus that will increase the risk for ACS.

3. Losing as little as 5% of ones body weight will significantly lower the risk for ACS.

4. Obesity, a BMI of greater than 30, increases the risk for ACS.

Correct Answer: 4

Rationale 1: Excessive weight will increase low-density lipoproteins.

Rationale 2: Extra weight can lead to the development of diabetes mellitus.

Rationale 3: A weight loss of 10% has been shown to improve risk for ACS.

Rationale 4: Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-1: Explain acute coronary syndrome.

Question 5

Type: MCSA

When a patient says, The chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue, the pain will most likely be classified as:

1. Variant or Prinzmetals angina

2. Undifferentiated angina

3. Unstable angina

4. Stable angina

Correct Answer: 4

Rationale 1: Variant or Prinzmetals angina occurs in an unpredictable pattern that is caused by vasospasm and cause transient ST-segment elevation. These are best treated with calcium channel blockers.

Rationale 2: There is no such term used to describe angina.

Rationale 3: Unstable angina does not respond well to nitroglycerin (NTG) and has no set pattern. The pain can occur at rest and with minimal exertion.

Rationale 4: Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2: Differentiate among different types of acute coronary syndrome.

Question 6

Type: MCSA

A patient tells a nurse, My chest pain starts when I am resting, and when I had a cardiac catheterization, the doctor said I was having vasospasms. Which type of medication would the nurse anticipate to be prescribed to treat the patients angina?

1. A vasodilator such as nitroglycerin (NTG)

2. A calcium channel blocking agent

3. An antidysrhythmic such as lidocaine

4. A beta adrenergic blocking agent

Correct Answer: 2

Rationale 1: NTG is used with stable angina, not Prinzmetals angina.

Rationale 2: Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetals angina.

Rationale 3: Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary vasospasm.

Rationale 4: Beta adrenergic blocking agents are used to treat stable angina.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-2: Differentiate among different types of acute coronary syndrome.

Question 7

Type: MCSA

The nurse is instructing a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed?

1. A heart attack is the same as a myocardial infarction (MI).

2. A heart attack causes tissue death and that part of the heart may not pump as well.

3. A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well.

4. Angina always leads first to decreased blood flow to the heart muscle and then to tissue death.

Correct Answer: 4

Rationale 1: This is correct information. No clarification is needed by the nurse.

Rationale 2: This is correct information. No clarification is needed by the nurse.

Rationale 3: This is correct information. No clarification is needed by the nurse.

Rationale 4: Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-2: Differentiate among different types of acute coronary syndrome.

Question 8

Type: MCSA

What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

1. Gathering a complete medical history

2. Performing a 12-lead ECG

3. Administering NTG to see if the pain goes away

4. Asking the patient if performing a Valsalva maneuver reduces the pain

Correct Answer: 2

Rationale 1: Reviewing a complete history will waste time in what might be an emergent situation.

Rationale 2: A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin.

Rationale 3: Just experimenting with a drug such as NTG should not be the first choice for differentiating the source of the chest pain. Also it is unsafe to give a drug without a specific reason or cause.

Rationale 4: Performing the Valsalva maneuver will increase abdominal and thoracic pressures and can cause vagal stimulation that will result in decreased heart rate. It should not be suggested unless tachycardia is present and emergency equipment is available in case of cardiac arrest. This is not a method of differentiating the types of chest pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3: Describe emergent assessment and collaborative management of the person with chest discomfort.

Question 9

Type: MCSA

An 80-year-old woman has arrived in the emergency department. The health care provider is questioning whether she has had an MI although she is not displaying the classic chest pain. Which symptoms would more likely occur in this patient than others because of the patients gender and age?

1. Jaw and/or tooth pain

2. Centralized chest pain

3. Generalized fatigue accompanied by dyspnea and diaphoresis

4. Dyspnea accompanied by crackles in all lobes

Correct Answer: 3

Rationale 1: This is a symptom of cardiac disease and can occur in men and women, so it is not a differential for women.

Rationale 2: Centralized chest pain is more likely to occur in men than in women.

Rationale 3: Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men.

Rationale 4: Rales are evidence of fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can have dyspnea and, therefore, it is not a differential factor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3: Describe emergent assessment and collaborative management of the person with chest discomfort.

Question 10

Type: MCSA

Which laboratory value would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier?

1. CK

2. Troponin T assay

3. Myoglobin

4. PTT

Correct Answer: 3

Rationale 1: Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to validate an MI.

Rationale 2: Troponin T assay is the most sensitive for cardiac damage but does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to normal after 4 to 10 days.

Rationale 3: Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred.

Rationale 4: PTT does not measure tissue damage; it measures serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an MI occurred.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary event.

Question 11

Type: MCMA

The multidisciplinary team would identify which goals for initial collaborative management of a patient with an acute coronary event (ACS)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Limit the size of infarction by decreasing oxygen demands.

2. Maximize coronary artery blood flow.

3. Strengthen the heart by increasing activity as soon as possible.

4. Balance oxygen demand with supply.

5. Prevent dysrhythmias with prophylactic antidysrhythmic medications.

Correct Answer: 1,2,4

Rationale 1: The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death).

Rationale 2: In a collaborative environment, maximization of coronary artery blood flow would be achieved through medication therapy, procedural intervention, and rest.

Rationale 3: Ambulation will increase demand for O2 and is not recommended until the patient is stable.

Rationale 4: The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death.

Rationale 5: Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-3: Describe emergent assessment and collaborative management of the person with chest discomfort.

Question 12

Type: MCSA

A patient is admitted with chest discomfort and a possible UA/NSTEMI. What would be a contraindication to administration of GP-IIb-IIIA inhibitors to the patient? The patient had:

1. Major surgery in the last 6 months

2. A creatinine level of 1.4 mg/dL

3. A stroke within the past month

4. A platelet count greater than 150,000 mm3

Correct Answer: 3

Rationale 1: This is not a contraindication for the administration of this medication.

Rationale 2: This is not a contraindication for the administration of this medication.

Rationale 3: The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration.

Rationale 4: This is not a contraindication for the administration of this medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5: Compare and contrast fibrinolysis and angioplasty for emergent reperfusion of the cardiac patient.

Question 13

Type: MCSA

The electrocardiogram of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding?

1. The spasm in the coronary artery has resolved.

2. The myocardial injury is evolving.

3. The patient has become more relaxed.

4. The blocked artery has been reperfused.

Correct Answer: 4

Rationale 1: This is not what the electrocardiogram tracing is indicating.

Rationale 2: This is not what the electrocardiogram tracing is indicating.

Rationale 3: This is not what the electrocardiogram tracing is indicating.

Rationale 4: Early reperfusion can resolve coronary ischemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5: Differentiate between fibrinolysis and PCI for emergent reperfusion of the cardiac patient.

Question 14

Type: MCSA

A nurse is preparing to administer the first 5 mg dose of metoprolol (Toprol) to a patient who is 12 hours post MI. For which assessment finding should the nurse withhold administration of the medication?

1. Serum potassium 3.9 mEq/L

2. Blood pressure of 110/65 mm Hg

3. PR interval 0.12 second

4. Sinus bradycardia 52 beats per minute

Correct Answer: 4

Rationale 1: The medication would not need to be withheld for this laboratory value.

Rationale 2: The medication can be given with this blood pressure.

Rationale 3: This medication can be given with this PR interval.

Rationale 4: Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and third-degree heart block, and active asthma and/or reactive airway disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-3: Describe emergent assessment and collaborative management of the person with chest discomfort.

Question 15

Type: MCSA

Following angioplasty, a patient develops the following: hematuria, hypotension, tachycardia, a drop in hemoglobin and hematocrit, and a decrease in oxygen saturation. What is most likely the cause for these symptoms?

1. Reaction to vasovagal stimulation

2. Myocardial ischemia

3. Peripheral emboli distal to the insertion site

4. Over-anticoagulation

Correct Answer: 4

Rationale 1: Vasovagal symptoms would include decreasing heart rate and not impact the H/H or O2 saturation levels. Blood pressure may be down and fainting usually occurs with orthostatic positioning.

Rationale 2: Ischemia may cause BP and HR symptoms with changes in O2 saturation but not the decline in H/H.

Rationale 3: Emboli distal to the insertion site will not alter the BP, HR, H/H, or O2 saturation. The pulses will be diminished or absent depending on the degree of obstruction or the size of thrombi.

Rationale 4: The symptoms are a result of over-anticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-6: Describe nursing management of the patient post PCI.

Question 16

Type: MCSA

A nurse is caring for a patient who has just started to bleed from the insertion site following a cardiac catheterization. What should be the nurses first response? The nurse should:

1. Administer vitamin K (AquaMEPHYTON).

2. Locate and apply a compression clamp.

3. Apply a collagen patch or sheath.

4. Apply manual pressure to the site.

Correct Answer: 4

Rationale 1: Vitamin K is an antidote for warfarin. It increases hepatic biosynthesis of blood-clotting factors. But it is not a treatment for an active bleed.

Rationale 2: This might take too much time and might be done later.

Rationale 3: This might take too much time and might be done later.

Rationale 4: The nurse should immediately apply manual pressure to the site.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-6: Describe nursing management of the patient post PCI.

Question 17

Type: MCMA

To increase compliance and reduce postoperative complications, the nurse should include which topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Reasons for cooling blankets in post-op period

2. Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads

3. Alternate methods for communicating when intubated

4. Reasons and techniques of turning, coughing, and deep breathing once extubated

5. Drug management: need for sedation when intubated, pain med through PCA

Correct Answer: 2,3,4,5

Rationale 1: During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures.

Rationale 2: This should be included in the teaching.

Rationale 3: This should be included in the teaching for the patient and family.

Rationale 4: This should be included in the teaching.

Rationale 5: This should be included in the teaching.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-7: Discuss care of the patient following coronary artery bypass surgery.

Question 18

Type: MCSA

What would be included in the collaborative management of a patients pulmonary status following coronary artery bypass graft surgery?

1. Keeping the patient intubated for at least 48 hours to maximize gas exchange

2. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis

3. Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45

4. Extubating when the patient is arousable to noxious stimuli and shows increased effort for spontaneous breathing

Correct Answer: 2

Rationale 1: No set timing is required for extubation readiness is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O2 exchange during the first 24 hours after surgery.

Rationale 2: Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected.

Rationale 3: The goal settings for adequate ventilation are off: O2 greater than 80 mm Hg, FiO2 less than 40%, and PCO2 less than 45.

Rationale 4: Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O2 demand when readiness has been achieved. With increased respiratory effort, more O2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patients response.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-7: Discuss care of the patient following coronary artery bypass surgery.

Question 19

Type: MCMA

Which findings would cause the nurse to suspect that a post-coronary artery bypass patient might be developing cardiac tamponade?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Widening pulse pressure

2. Increased jugular vein distension

3. Decreasing central venous pressure (CVP)

4. Muffled heart sounds

5. Lack of pleural (chest) tube drainage

Correct Answer: 2,4,5

Rationale 1: The pulse pressure will narrow, not widen, as fewer pressure differences are noted between the systolic and diastolic pressures.

Rationale 2: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins.

Rationale 3: The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion.

Rationale 4: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The fluid surrounding the heart muffles the heart sounds.

Rationale 5: Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-7: Discuss care of the patient following coronary artery bypass surgery.

Question 20

Type: MCMA

Which factors would contribute to the risk of a patient developing stress ulcers after coronary artery bypass graft (CABG) surgery?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Incidence of postoperative hemorrhaging

2. Age less than 70 years

3. Alcohol abuse or excess

4. Need for vasodilators for post-operative hypertension

5. Prolonged use of cardiopulmonary bypass

Correct Answer: 1,3,5

Rationale 1: Bleeding disorders increases the risk for stress ulcers in the post-operative period.

Rationale 2: The age for increased risk is over 70 years old, not under 70.

Rationale 3: History of alcohol abuse or excess increases the risk for stress ulcer formation in the patient recovering from this type of surgery.

Rationale 4: The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator.

Rationale 5: Prolonged use of cardiopulmonary bypass increases the risk for stress ulcer formation in the patient recovering from this type of surgery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-7: Discuss care of the patient following coronary artery bypass surgery.

Question 21

Type: MCSA

A patient starting cardiac rehabilitation will work with the rehabilitation team to meet all of the following goals except:

1. Taking control of his life through healthy choices

2. Managing symptoms by monitoring exercise

3. Reducing risks by controlling the modifiable risk factors

4. Stabilizing any severe depression that developed post-MI

Correct Answer: 4

Rationale 1: This is a goal of the program.

Rationale 2: This is a goal of the program.

Rationale 3: This is a goal of the program.

Rationale 4: The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-8: Prioritize discharge teaching for the patient who has had an acute coronary event.

Question 22

Type: MCSA

The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. The nurse should suggest:

1. Decreasing sodium intake to less than 1,500 mg/day

2. Losing weight

3. Increasing intake of dairy products

4. Controlling diabetes to an A1C less than 7%

Correct Answer: 1

Rationale 1: Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP.

Rationale 2: Losing weight will not cause the largest reduction in BP.

Rationale 3: Increasing the intake of dairy products will not cause the largest reduction in BP.

Rationale 4: Controlling diabetes to an A1C less than 7% will not cause the largest reduction in BP.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-8: Prioritize discharge teaching for the patient who has had an acute coronary event.

Question 23

Type: MCSA

A nurse is teaching a patient with coronary artery disease about prescribed nitroglycerin therapy. Which patient statement indicates further teaching is needed?

1. If the pain doesnt go away I can take a second tablet after 5 minutes.

2. I should not take nitroglycerin if I have taken Viagra.

3. I should try to sit or lie down when I take the nitroglycerin.

4. Ill put a couple of tablets in a plastic bag in my pocket so I have them with me all the time.

Correct Answer: 4

Rationale 1: This would not indicate that further teaching is needed.

Rationale 2: This would not indicate that further teaching is needed.

Rationale 3: This would not indicate that further teaching is needed.

Rationale 4: Nitroglycerin should be kept in a tightly sealed brown bottle.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-8: Prioritize discharge teaching for the patient who has had an acute coronary event.

Question 24

Type: MCSA

A patient is being discharged after an MI and is prescribed lisinopril (Prinivil) 10 mg daily. Which instruction is most appropriate for the nurse to give to the patient?

1. Avoid crossing your legs.

2. Weigh yourself at least 3 times a week.

3. Cut down on your sodium intake to 1,500 mg/day.

4. Change your position slowly when going from lying to sitting.

Correct Answer: 4

Rationale 1: This is not the most appropriate instruction to provide to the patient about this medication.

Rationale 2: This is not the most appropriate instruction to provide to the patient about this medication.

Rationale 3: This is not the most appropriate instruction to provide to the patient about this medication.

Rationale 4: Watching for postural hypotension when initiating therapy is important.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-8: Prioritize discharge teaching for the patient who has had an acute coronary event.

Question 25

Type: MCMA

The nurse is instructing a patient about acute coronary syndrome. What will be included in these instructions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fatty plaques develop in the coronary arteries.

2. Plaques in arteries limit the amount of blood that can flow through the heart vessels.

3. Plaque in coronary arteries can cause stable angina.

4. If a plaque ruptures, it can get into the general circulation.

5. Stable angina rarely progresses to unstable angina.

Correct Answer: 1,2,3,4

Rationale 1: This would be included when teaching about acute coronary syndrome.

Rationale 2: The growth of the atherosclerotic plaques narrows the vasculature, which then limits the blood flow and delivery of oxygen to the coronary muscle. This would be included when teaching about acute coronary syndrome.

Rationale 3: This buildup of plaque in the coronary arteries results in a less serious condition known as stable angina. This would be included when teaching about acute coronary syndrome.

Rationale 4: Rupture of a thin fibrous cap exposes the thrombogenic contents of the plaque into a patients circulation. This would be included when teaching about acute coronary syndrome.

Rationale 5: This is incorrect. The fibrous cap over a plaque can rupture which can lead to occlusion of coronary vessels.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-1: Explain acute coronary syndrome.

Question 26

Type: MCMA

During a health history the nurse suspects a patient has been experiencing stable angina. What did the patient most likely describe to the nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Chest pain that lasts between 5 to 10 minutes

2. Chest pain that occurs during stress

3. Chest pain that occurs when out of doors on very cold days

4. Chest pain that stops with rest

5. Chest pain that occurs at rest

Correct Answer: 1,2,3,4

Rationale 1: This is a manifestation of stable angina.

Rationale 2: This is a manifestation of stable angina.

Rationale 3: This is a manifestation of stable angina.

Rationale 4: This is a manifestation of stable angina.

Rationale 5: This is a manifestation of unstable and variant angina.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2: Differentiate among different types of acute coronary syndrome.

Question 27

Type: SEQ

The nurse is beginning emergency care of a patient with a myocardial infarction. Place in order the medication interventions that the nurse will provide to this patient.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Administer four baby strength aspirins.

Choice 2. Administer nitroglycerin.

Choice 3. Apply oxygen.

Choice 4. Administer morphine 2 to 5 mg intravenous every 5 to 30 minutes as needed.

Choice 5. Administer a beta blocker.

Correct Answer: 1,2,3,4,5

Rationale 1: This is the first medication intervention that the nurse will provide. It is used to prevent platelet aggregation and the formation of blood clots in the coronary vasculature.

Rationale 2: This is the second medication intervention that the nurse will provide. It is used to reduce coronary pain and improve coronary blood flow.

Rationale 3: This is the third medication intervention that the nurse will provide. It is used to ensure adequate oxygenation of coronary tissues.

Rationale 4: This is the fourth medication intervention that the nurse will provide. Morphine is used for both pain management and as an anti-anxiety medication.

Rationale 5: This is the fifth medication intervention that the nurse will provide. Beta blockers should be promptly instituted because they decrease heart rate, and blood pressure levels. These drugs will also decrease left ventricular contractility, thereby reducing myocardial oxygen demand.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-3: Describe emergent assessment and collaborative management of the person with chest discomfort.

Question 28

Type: MCMA

A patient with chest pain is prescribed to have a troponin level drawn. What purpose does this diagnostic test serve in the care of a patient with chest pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It appears in the bloodstream 4 to 12 hours after the onset of cardiac injury.

2. The peak level of troponin appears in 12 hours.

3. If a cardiac injury has occurred, the troponin level will stay elevated for 7 to 10 days.

4. The troponin level may be a predictor of myocardial infarction size.

5. A negative result does not need to be retested.

Correct Answer: 1,2,3,4

Rationale 1: This marker appears in the bloodstream 4 to 12 hours after the onset of injury.

Rationale 2: This marker peaks in 12 hours.

Rationale 3: This marker remains elevated for 7 to 10 days after cardiac injury.

Rationale 4: After an acute myocardial infarction, it may be a predictor of size.

Rationale 5: It is recommended that a negative troponin level within 6 hours after the onset of symptoms be retested at 8 to 12 hours after the onset.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary event.

Question 29

Type: MCMA

The nurse instructs a patient on the procedure for percutaneous coronary intervention (PCI) with stent placement. Which patient statements indicate that teaching has been effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. This procedure is done on an artery that is about 70% smaller than it should be.

2. The artery in my heart is reached by going through an artery in my leg.

3. After the fatty clot is smashed against the artery wall, a mesh stent remains in the artery to keep it open.

4. I will need to take aspirin and another blood thinner for up to 6 months after the procedure.

5. I will have my blood sugar level measured many times after the procedure.

Correct Answer: 1,2,3,4

Rationale 1: PCI is indicated in coronary arteries that have at least 70% narrowing.

Rationale 2: A catheter with a balloon is inserted into the femoral artery and guided to the desired site.

Rationale 3: The balloon is inflated, expanding the stent which squeezes the atherosclerotic plaque against the vessel wall and widens the arterial lumen. After the stent is in place, the balloon is deflated and removed. The stent remains in place holding the plaque against the arterial wall providing structural support.

Rationale 4: Patients with stent placement usually require antiplatelet therapy with aspirin and clopidogrel for up to 6 months after stenting to reduce the risk of vessel thrombosis.

Rationale 5: The patients hemoglobin, hematocrit, and platelet levels should also be monitored. These can give indications for the tendency to bleed, especially if the patient has been given glycoprotein IIb/IIIa receptor inhibitors and/or tPA because these can cause thrombocytopenia. This is not an indication for care after a PCI with stent placement. The patients blood glucose level does not need to be monitored.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5: Differentiate between fibrinolysis and PCI for emergent reperfusion of the cardiac patient.

Question 30

Type: MCMA

What interventions will the nurse include when planning care for a patient recovering from PCI with stent placement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor for reperfusion dysrhythmias.

2. Monitor for bleeding from the catheter site.

3. Assess for pulses at the ankle and knee.

4. Maintain the patient on bedrest with the cannulated extremity straight for 4 to 6 hours.

5. Administer blood products for low blood pressure as prescribed.

Correct Answer: 1,2,3,4

Rationale 1: This is an appropriate intervention for a patient recovering from PCI with stent placement.

Rationale 2: This is an appropriate intervention for a patient recovering from PCI with stent placement.

Rationale 3: This is an appropriate intervention for a patient recovering from PCI with stent placement. The nurse should monitor the extremity below the insertion site for pulses.

Rationale 4: This is an appropriate intervention for a patient recovering from PCI with stent placement.

Rationale 5: This is not an appropriate intervention for a patient recovering from PCI with stent placement. It would be appropriate for the patient recovering from coronary artery bypass grafting.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-6: Describe nursing management of the patient post-PCI.

Question 31

Type: MCMA

A patient recovering from coronary artery bypass grafting is experiencing dysrhythmias. What will the nurse assess as the reasons for the dysrhythmias?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Patients body temperature

2. Potassium level

3. Calcium level

4. Arterial blood gases

5. Pupil size and reactivity to light

Correct Answer: 1,2,3,4

Rationale 1: Hypothermia can cause dysrhythmias after this type of surgery.

Rationale 2: Hypokalemia can cause dysrhythmias after this type of surgery.

Rationale 3: Hypo- and hypercalcemia can cause dysrhythmias after this type of surgery.

Rationale 4: Metabolic acidosis can cause dysrhythmias after this type of surgery.

Rationale 5: Pupil response is used to assess the patients neurologic status after this type of surgery and does not influence the development of dysrhythmias.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-7: Discuss care of the patient following coronary artery bypass surgery.

Question 32

Type: MCMA

A patient with type 2 diabetes mellitus is prescribed nicotinic acid (Nicobid) as adjunctive therapy for hypercholesterolemia. What will the nurse instruct the patient about this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Instruct to check blood glucose level frequently for elevations.

2. Teach that this medication may cause the patient to feel warm.

3. Instruct the patient that a flushed face can occur within 2 hours after taking.

4. Teach to not take medication with grapefruit juice.

5. Remind to notify the health care provider with any onset of muscle pain.

Correct Answer: 1,2,3

Rationale 1: This medication can increase the blood glucose level.

Rationale 2: Feeling warm is an expected response to this medication.

Rationale 3: A flushed face can occur within 2 hours after ingesting this medication.

Rationale 4: This medication does not react with grapefruit juice.

Rationale 5: This medication does not cause muscle pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 6-8: Prioritize discharge teaching for the patient who has had an acute coronary event.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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