Chapter 23: Management of Patients with Coronary Vascular Disorders

Question 1

1. The nurse is caring for a client who has been diagnosed with an elevated cholesterol
   level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly
   of what?
   A. Lipids and fibrous tissue
   B. White blood cells
   C. Lipoproteins
   D. High-density cholesterol

Answer 1

ANS: A
Rationale: As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall
and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen
of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.

Question 2

2. A client presents to the clinic reporting intermittent chest pain on exertion, which is
   eventually attributed to angina. The nurse should inform the client that angina is most
   often attributable to what cause?
   A. Decreased cardiac output
   B. Decreased cardiac contractility
   C. Infarction of the myocardium
   D. Coronary arteriosclerosis

Answer 2

ANS: D
Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a
result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

Question 3

3. The nurse is caring for an adult client who had symptoms of unstable angina upon
   admission to the hospital. What nursing diagnosis underlies the discomfort associated
   with angina?
   A. Ineffective breathing pattern related to decreased cardiac output
   B. Anxiety related to fear of death
   C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease
   (CAD)
   D. Impaired skin integrity related to CAD

Answer 3

ANS: C
Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

Question 4

4. The triage nurse in the ED assesses an adult client who presents with reports of
   midsternal chest pain that has lasted for the last 5 hours. If the client’s symptoms are due
   to an MI, what will have happened to the myocardium?
   A. It may have developed an increased area of infarction during the time without
   treatment.
   B. It will probably not have more damage than if the client came in immediately.
   C. It may be responsive to restoration of the area of dead cells with proper
   treatment.
   D. It has been irreparably damaged, so immediate treatment is no longer
   necessary.

Answer 4

ANS: A
Rationale: When the client experiences lack of oxygen to myocardium cells during an MI,
the sooner treatment is initiated, the more likely the treatment will prevent or minimize
myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

Question 5

5. Family members bring a client to the ED with pale cool skin, sudden midsternal chest
   pain unrelieved with rest, and a history of CAD. How should the nurse best interpret
   these initial data?
   A. The symptoms indicate angina and should be treated as such.
   B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology.
   C. The symptoms indicate an acute coronary episode and should be treated as
   such.
   D. Treatment should be determined pending the results of an exercise stress test.

Answer 5

ANS: C
Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client’s symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

Question 6

6. An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR
   nurse knows that what vessel is most commonly used as source for a CABG?
   A. Brachial artery
   B. Brachial vein
   C. Femoral artery
   D. Greater saphenous vein

Answer 6

ANS: D
Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

Question 7

7. A client with an occluded coronary artery is admitted and has an emergency
   percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the
   cardiac critical care unit after the PTCA. The complications for which the nurse should
   monitor the client include which of the following?
   A. Peripheral edema
   B. Bleeding at insertion site
   C. Left ventricular hypertrophy
   D. Pulmonary edema

Answer 7

ANS: B
Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt
closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include left ventricular hypertrophy because this problem takes an extended time to develop and is not emergent. Bleeding is a more likely and more serious complication than edema.

Question 8

8. A client with type 2 diabetes and hypertension (HTN) has a routine follow-up
   appointment after a cardiac stent placement. On assessment the nurse notes the client
   weighs 250 lb/113.4 kg with a waist circumference of 40 inches/101.6 cm, blood
   pressure is 162/84 mm Hg, and fasting blood glucose is 220 mg/dl. Based on these
   findings, which syndrome should the nurse most suspect?
   A. Adams-Nance syndrome
   B. Postpericardiotomy syndrome
   C. Metabolic syndrome
   D. Alagille syndrome

Answer 8

ANS: C
Rationale: A cluster of metabolic abnormalities known as metabolic syndrome is a major
risk factor for cardiovascular disease. This diagnosis is made when the client has 3 of the 5 risk factors. These factors include a waist circumference of greater than 35.4
inches/89.9 cm, elevated triglycerides, reduced high-density lipoprotein cholesterol, HTN with a systolic blood pressure above 130 mm Hg, and fasting glucose greater than 100 mg/dL or drug treatment for elevated glucose. Adams-Nance syndrome is an inherited
disorder characterized by paroxysmal tachycardia, arterial HTN, syncope, and seizures. Alagille syndrome is a rare genetic disorder that can affect multiple organ systems including the liver, heart, skeleton, eyes, and kidneys. Based on the information presented neither of the above syndromes is likely. Postpericardiotomy syndrome may occur to clients days or weeks after surgery, so a possibility exists, but the signs and symptoms are not presented. Postpericardiotomy is characterized by fever, pericardial/pleural/joint pain, friction rub, and dyspnea.

Question 9

9. The OR nurse is explaining to a client that cardiac surgery requires the absence of
   blood from the surgical field. At the same time, it is imperative to maintain perfusion of
   body organs and tissues. What technique for achieving these simultaneous goals should
   the nurse describe?
   A. Coronary artery bypass graft (CABG)
   B. Percutaneous transluminal coronary angioplasty (PTCA)
   C. Atherectomy
   D. Cardiopulmonary bypass

Answer 9

ANS: D
Rationale: Cardiopulmonary bypass is often used to circulate and oxygenate blood
mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all
surgical procedures, none of which achieves the two goals listed.

Question 10

10. The nurse has just admitted a client for cardiac surgery. The client tearfully describes
    feeling afraid of dying while undergoing the surgery. What is the nurse’s best response?
    A. Explore the factors underlying the client’s anxiety.
    B. Teach the client guided imagery techniques.
    C. Obtain an order for a PRN benzodiazepine.
    D. Describe the procedure in greater detail.

Answer 10

ANS: A
Rationale: An assessment of anxiety levels is required in the client to assist the client in
identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client’s anxiety before providing interventions such as education or medications.

Question 11

11. A client with angina has been prescribed nitroglycerin. Before administering the drug,
    the nurse should inform the client about what potential adverse effects?
    A. Nervousness or paresthesia
    B. Throbbing headache or dizziness
    C. Drowsiness or blurred vision
    D. Tinnitus or diplopia

Answer 11

ANS: B
Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

Question 12

12. The nurse is providing an educational workshop about coronary artery disease (CAD)
    and its risk factors. The nurse explains to participants that CAD has many risk factors,
    some that can be controlled and some that cannot. Which risk factors should the nurse
    list that can be controlled or modified?
    A. Gender, obesity, family history, and smoking
    B. Inactivity, stress, gender, and smoking
    C. Cholesterol levels, hypertension, and smoking
    D. Stress, family history, and obesity

Answer 12

ANS: C
Rationale: Four modifiable risk factors—cholesterol abnormalities, tobacco use,
hypertension, and diabetes—are established risk factors for CAD and its complications. Inactivity and obesity are also modifiable risk factors associated with CAD. Stress, although not listed as a direct risk factor for CAD, contributes to hypertension, which is itself a risk factor. Gender and family history are risk factors that cannot be controlled.

Question 13

13. A client presents to the ED reporting severe substernal chest pain radiating down the
    left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of
    myocardial infarction (MI). What nursing assessment activity is a priority on admission to
    the CCU?
    A. Begin ECG monitoring.
    B. Obtain information about family history of heart disease.
    C. Auscultate lung fields.
    D. Determine if the client smokes.

Answer 13

ANS: A
Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the client smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

Question 14

14. The public health nurse is participating in a health fair and interviews a client with a
    history of hypertension, who is currently smoking one pack of cigarettes per day. The
    client denies any of the most common manifestations of CAD. The nurse should expect
    the focuses of CAD treatment to be:
    A. drug therapy and smoking cessation.
    B. diet and drug therapy.
    C. diet therapy only.
    D. diet therapy and smoking cessation.

Answer 14

ANS: D
Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as
the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

Question 15

15. The nurse is working with a client who had an MI and is now active in rehabilitation.
    The nurse should teach this client to cease activity if which of the following occurs?
    A. The client experiences chest pain, palpitations, or dyspnea.
    B. The client experiences a noticeable increase in heart rate during activity.
    C. The client’s oxygen saturation level drops below 96%.
    D. The client’s respiratory rate exceeds 30 breaths/min.

Answer 15

ANS: A
Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the client with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most clients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

Question 16

16. A client with cardiovascular disease is being treated with amlodipine, which is
    intended to cause what therapeutic effect?
    A. Reducing the heart’s workload by decreasing heart rate and myocardial
    contraction
    B. Preventing platelet aggregation and subsequent thrombosis
    C. Reducing myocardial oxygen consumption by blocking adrenergic stimulation to
    the heart
    D. Increasing the efficiency of myocardial oxygen consumption, thus decreasing
    ischemia and relieving pain

Answer 16

ANS: A
Rationale: Calcium channel blocking agents decrease sinoatrial node automaticity and
atrioventricular node conduction, resulting in a slower heart rate and a decrease in the
strength of the heart muscle contraction. These effects decrease the workload of the
heart. Antiplatelet and anticoagulation medications are given to prevent platelet
aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers
reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to
the heart. The result is reduced myocardial contractility (force of contraction) to balance
the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen
consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

Question 17

17. The nurse is providing care for a client with high cholesterol and triglyceride values.
    In teaching the client about therapeutic lifestyle changes such as diet and exercise, the
    nurse realizes that the desired goal for cholesterol levels is which of the following?
    A. High HDL values and high triglyceride values
    B. Absence of detectable total cholesterol levels
    C. Elevated blood lipids, fasting glucose less than 100
    D. Low LDL values and high HDL values

Answer 17

ANS: D
Rationale: The desired goal for cholesterol readings is for a client to have low LDL and
high HDL values. LDL exerts a harmful effect on the coronary vasculature because the
small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

Question 18

18. A nurse educator is conducting an inservice for nursing students about how tobacco
    use impacts coronary artery disease (CAD)? What are the primary ways that tobacco
    use impacts CAD? Select all that apply.
    A. Decreases the supply of oxygen to the myocardium
    B. Increases platelet adhesion
    C. Raises the heart rate and blood pressure
    D. Causes the coronary arteries to dilate
    E. Increases the blood carbon monoxide level

Answer 18

ANS: A, B, C, E
Rationale: Nicotinic acid in tobacco triggers the release of catecholamines (hormones
that are released due to stress), which raise the heart rate and blood pressure and cause coronary arteries to constrict. This increases the risk of CAD and sudden cardiac death. Tobacco use also increases oxidation of low-density lipoprotein (good) cholesterol, which results in increased platelet adhesion and thrombus formation. Ischemia and reduced contractility can result in the increase in carbon monoxide levels and decreased oxygenation of the myocardium.

Question 19

19. The nurse is caring for a client who is believed to have just experienced an MI. The
    nurse notes changes in the ECG of the client. What change on an ECG most strongly
    suggests to the nurse that ischemia is occurring?
    A. P-wave inversion
    B. T-wave inversion
    C. Qwave changes with no change in ST or T wave
    D. P-wave enlargement

Answer 19

ANS: B
Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

Question 20

20. An adult client is admitted to the ED with chest pain. The client states that there was
    unrelieved chest pain for approximately 20 minutes before coming to the hospital. To
    minimize cardiac damage, the nurse should expect to administer which of the following
    interventions?
    A. Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal
    anti-inflammatories
    B. Morphine sulphate, oxygen, and bed rest
    C. Oxygen and beta-adrenergic blockers
    D. Bed rest, albuterol nebulizer treatments, and oxygen

Answer 20

ANS: B
Rationale: The client with suspected MI should immediately receive supplemental
oxygen, aspirin, nitroglycerin, and morphine. Morphine reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

Question 21

21. A client with hypertension is ambulating in the hospital hallway and reports chest
    pain. In which order would the nurse assess and treat this client?
    A. The first set of vital signs are done.
    B. The nurse assesses the client’s angina.
    C. A 12-lead electrocardiogram (ECG) is performed.
    D. The client is instructed to stop all activity.
    E. The client receives the first dose of nitroglycerin.
    F. The client is transferred to a higher acuity unit.

Answer 21

ANS: D, B, A, C, E, F
Rationale: The client is first directed to stop all activity and sit, rest, and/or is placed in a
semi-Fowler position to reduce the oxygen workload on the heart. The nurse then
assesses the client’s chest pain/angina to determine whether it is the same as the client typically experiences. Vital signs are performed next and any respiratory distress is noted at this time. Typically oxygen is applied at this time, but because the sequence was not specifically spelled out, it was not included. VSS provides information on the damage to the heart that may or may not be occurring. A 12-lead ECG is performed, which continues
to support or eliminate a cardiac event. Nitroglycerin is given sublingually up to 3 doses. It is a vasodilator that opens up blood vessels to improve blood flow and decrease chest pain. If the chest pain continues after interventions and/or a myocardial infarction is diagnosed, the client may be transferred to a higher acuity unit.

Question 22

22. In preparation for cardiac surgery, a client was taught about measures to prevent
    venous thromboembolism. What statement indicates that the client clearly understood
    this education?
    A. “I’ll try to stay in bed for the first few days to allow myself to heal.”
    B. “I’ll make sure that I don’t cross my legs when I’m resting in bed.”
    C. “I’ll keep pillows under my knees to help my blood circulate better.”
    D. “I’ll put on those compression stockings if I get pain in my calves.”

Answer 22

ANS: B
Rationale: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

Question 23

23. When assessing a client diagnosed with angina pectoris, it is most important for the
    nurse to gather what information?
    A. The client’s activities, limitations, and level of consciousness after the attacks
    B. The client’s symptoms and the activities that precipitate attacks
    C. The client’s understanding of the pathology of angina
    D. The client’s coping strategies surrounding the attacks

Answer 23

ANS: B
Rationale: The nurse must gather information about the client’s symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client’s coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

Question 24

24. The nurse is writing a care plan for a client who has been diagnosed with angina
    pectoris. The client describes herself as being “distressed” and “shocked” by the new
    diagnosis. What nursing diagnosis is most clearly suggested by the client’s statement?
    A. Spiritual distress related to change in health status
    B. Acute confusion related to prognosis for recovery
    C. Anxiety related to cardiac symptoms
    D. Deficient knowledge related to treatment of angina pectoris

Answer 24

ANS: C
Rationale: Although further assessment is warranted, it is not unlikely that the client is
experiencing anxiety. In clients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to the client’s concerns. Similarly, it is not clear that a lack of knowledge or information is the root of the client’s anxiety.

Question 25

25. The hospital nurse is caring for a client who reports that an angina attack is
    beginning. Which action is the nurse’s most appropriate initial action?
    A. Have the client sit down and put the head between the knees.
    B. Have the client perform pursed-lip breathing.
    C. Have the client stand still and bend over at the waist.
    D. Place the client on bed rest in a semi-Fowler position.

Answer 25

ANS: D
Rationale: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put the head between the legs because cerebral perfusion is not lacking

Question 26

26. A nurse is assigned four clients with diagnoses that rule out myocardial infarction
    (MI) due to chest pain. Which client’s test results best demonstrate the specific diagnosis
    of unstable angina (USA)?
    A. A 63-year-old client with elevated troponins and no elevation in the ST segment.
    B. A 72-year-old client with an increase in myoglobin, no elevation in the ST
    segment, and no elevation in troponins.
    C. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and
    ST segment elevations in two contiguous leads on the electrocardiogram (ECG).
    D. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q
    waves.

Answer 26

ANS: B
Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary
ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI.
The 48- and 54-year-old clients had test results consistent with an ST-elevated
myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous
leads, ST elevation, and Q wave abnormalities.

Question 27

27. The ED nurse is caring for a client with a suspected MI. What drug should the nurse
    anticipate administering to this client?
    A. Oxycodone
    B. Warfarin
    C. Morphine
    D. Acetaminophen

Answer 27

ANS: C
Rationale: The client with suspected MI is given aspirin, nitroglycerin, morphine, an IV
beta-blocker, and other medications as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

Question 28

28. The nurse is assessing a client with acute coronary syndrome (ACS). The nurse
    includes a careful history in the assessment, especially with regard to signs and
    symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
    A. Dyspnea
    B. Unusual fatigue
    C. Hypotension
    D. Syncope
    E. Peripheral cyanosis

Answer 28

ANS: A, B, D
Rationale: Systematic assessment includes a careful history, particularly as it relates to
symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

Question 29

29. The nurse is creating a plan of care for a client with acute coronary syndrome. What
    nursing action should be included in the client’s care plan?
    A. Facilitate daily arterial blood gas (ABG) sampling.
    B. Administer supplementary oxygen, as needed.
    C. Have client maintain supine positioning when in bed.
    D. Perform chest physiotherapy, as indicated.

Answer 29

ANS: B
Rationale: Oxygen should be given along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs
are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest
physiotherapy is not used in the treatment of ACS.

Question 30

30. The nurse is participating in the care conference for a client with ACS. What goal
    should guide the care team’s selection of assessments, interventions, and treatments?
    A. Maximizing cardiac output while minimizing heart rate
    B. Decreasing energy expenditure of the myocardium
    C. Balancing myocardial oxygen supply with demand
    D. Increasing the size of the myocardial muscle

Answer 30

ANS: C
Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium’s energy expenditure is often beneficial, but this must be balanced with productivity.

Question 31

31. The nurse working on the coronary care unit is caring for a client with ACS. How can
    the nurse best meet the client’s psychosocial needs?
    A. Reinforce the fact that treatment will be successful.
    B. Facilitate a referral to a chaplain or spiritual leader.
    C. Increase the client’s participation in rehabilitation activities.
    D. Directly address the client’s anxieties and fears.

Answer 31

ANS: D
Rationale: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the client’s psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some clients, but it may exacerbate it for others.

Question 32

32. The nurse is caring for a client who has undergone percutaneous transluminal
    coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
    A. Increase in the size of the artery’s lumen
    B. Decrease in arterial blood flow in relation to venous flow
    C. Increase in the client’s resting heart rate
    D. Increase in the client’s level of consciousness (LOC)

Answer 32

ANS: A
Rationale: PTCA is used to open blocked coronary vessels and resolve ischemia. The
procedure may result in beneficial changes to the client’s LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

Question 33

33. A nurse has taken on the care of a client who had a coronary artery stent placed
    yesterday. When reviewing the client’s daily medication administration record, the nurse
    should anticipate administering what drug?
    A. Ibuprofen
    B. Clopidogrel
    C. Dipyridamole
    D. Acetaminophen

Answer 33

ANS: B
Rationale: Because of the risk of thrombus formation within the stent, the client receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

Question 34

34. A nurse is working with a client who has been scheduled for a percutaneous coronary
    intervention (PCI) later in the week. What anticipatory guidance should the nurse provide
    to the client?
    A. The client will remain on bed rest for 48 to 72 hours after the procedure.
    B. The client will be given vitamin K infusions to prevent bleeding following PCI.
    C. A sheath will be placed over the insertion site after the procedure is finished.
    D. The procedure will likely be repeated in 6 to 8 weeks to ensure success.

Answer 34

ANS: C
Rationale: A sheath is placed over the PCI access site and kept in place until adequate
coagulation is achieved. Clients resume activity a few hours after PCI and repeated
treatments may or may not be necessary. Anticoagulants, not vitamin K, are given during PCI.

Question 35

35. The nurse is caring for a client who will have coronary artery revascularization. When
    explaining the pre- and postoperative regimens, the nurse should address which subject?
    A. Symptoms of hypovolemia
    B. Symptoms of low blood pressure
    C. Complications requiring graft removal
    D. Intubation and mechanical ventilation

Answer 35

ANS: D
Rationale: Most clients remain intubated and on mechanical ventilation for several hours after surgery. It is important that clients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most clients. Teaching would also generally not include rare complications that would require graft removal.

Question 36

36. A client in the cardiac step-down unit has begun bleeding from the percutaneous
    coronary intervention (PCI) access site in the femoral region. What is the nurse’s most
    appropriate action?
    A. Call for assistance and initiate cardiopulmonary resuscitation.
    B. Reposition the client’s leg in a nondependent position.
    C. Promptly remove the femoral sheath.
    D. Call for help and apply pressure to the access site.

Answer 36

ANS: D
Rationale: The femoral sheath produces pressure on the access site. Pressure will
temporarily reduce bleeding and allow for subsequent interventions. Removing the
sheath would exacerbate bleeding and repositioning would not halt it. CPR is not
indicated unless there is evidence of respiratory or cardiac arrest.

Question 37

37. The nurse providing care for a client post PTCA knows to monitor the client closely.
    For what complications should the nurse monitor the client? Select all that apply.
    A. Abrupt closure of the coronary artery
    B. Venous insufficiency
    C. Bleeding at the insertion site
    D. Retroperitoneal bleeding
    E. Arterial occlusion

Answer 37

ANS: A, C, D, E
Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute kidney injury. Venous insufficiency is not a postprocedure complication of a PTCA.

Question 38

38. A client who is postoperative day 1 following a CABG has produced 20 mL of urine in
    the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What
    is the nurse’s most appropriate action?
    A. Document the client’s low urine output and monitor closely for the next several
    hours.
    B. Contact the dietitian and suggest the need for increased oral fluid intake.
    C. Contact the client’s health care provider and continue to assess fluid balance and
    renal function.
    D. Increase the infusion rate of the client’s IV fluid to prompt an increase in renal
    function.

Answer 38

ANS: C
Rationale: Nursing management includes accurate measurement of urine output. An
output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

Question 39

39. A client is recovering in the hospital from cardiac surgery. The nurse has identified the
    diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What
    intervention best addresses this risk?
    A. Administration of bronchodilators by nebulizer
    B. Administration of inhaled corticosteroids by metered dose inhaler (MDI)
    C. Client’s consistent performance of deep–breathing and coughing exercises
    D. Client’s active participation in the cardiac rehabilitation program

Answer 39

ANS: C
Rationale: Clearance of pulmonary secretions is accomplished by frequent repositioning of the client, suctioning, and chest physical therapy, as well as educating and encouraging the client to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization
of respiratory secretions.

Question 40

40. An ED nurse is assessing a 71-year-old female client for a suspected MI. When
    planning the assessment, the nurse should be cognizant of what signs and symptoms of
    MI that are particularly common in female clients? Select all that apply.
    A. Shortness of breath
    B. Chest pain
    C. Anxiety
    D. Indigestion
    E. Nausea

Answer 40

ANS: D, E
Rationale: Many women experiencing coronary events, including unstable angina, MIs, or sudden cardiac death events, are asymptomatic or present with atypical symptoms. These symptoms include indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among clients of all ages and genders.