Chapter 38

Question 1

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?

Answer 1

Stop the infusion and call the provider.

Question 2

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client’s spouse asks why the client needs this medication. What response by the nurse is best?

Answer 2

“The heparin keeps that artery from getting blocked again.”

Question 3

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

Answer 3

Allow continued bathroom privileges.

Question 4

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best?

Answer 4

“Continue to educate the client on possible healthy changes.”

Question 5

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?

Answer 5

Prepare to administer a fluid bolus.

Question 6

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?

Answer 6

Ensure the balloon does not remain wedged.

Question 7

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client’s heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?

Answer 7

Assess the client for bleeding.

Question 8

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to “just get this over with” when asked to sign the consent form. What action by the nurse is best?

Answer 8

Tell the client that anxiety is common and that you can help.

Question 9

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?

Answer 9

“Do you have any concerns about sexuality?”

Question 10

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?

Answer 10

Maintain airway patency.

Question 11

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?

Answer 11

Assess for any hemodynamic effects of the rhythm.

Question 12

The nurse is preparing to change a client’s sternal dressing. What action by the nurse is most important?

Answer 12

Perform hand hygiene.

Question 13

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client’s sheets. What action should the nurse perform first?

Answer 13

Put on a pair of gloves.

Question 14

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?

Answer 14

Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg

Question 15

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?

Answer 15

“The best source is fish, but pills have benefits too.”

Question 16

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission’s Core Measures outcomes?

Answer 16

Give the client an aspirin.

Question 17

A nurse is caring for four clients. Which client should the nurse assess first?

Answer 17

Client who is 1 hour post angioplasty, has tongue swelling and anxiety

Question 18

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort?

Answer 18

Allow family members to remain at the bedside.

Question 19

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?

Answer 19

Notify the provider immediately.

Question 20

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?

Answer 20

Expired food in the refrigerator

Question 21

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?

Answer 21

Assess the IV site hourly.

Question 22

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?

Answer 22

Poor peripheral pulses and cool skin

Question 23

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission’s Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

Answer 23

1630 (4:30 PM)

Question 24

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse?

Answer 24

“It increases the force of the heart’s contractions.”

Question 25

A client had an inferior wall myocardial infarction (MI). The nurse notes the client’s cardiac rhythm as shown below:

What action by the nurse is most important?

Answer 25

Assess the client’s blood pressure and level of consciousness.

Question 26

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)

a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress

Answer 26

B,C,D,E

Question 27

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol.

Answer 27

A,C,E

Question 28

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)

a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause

Answer 28

A,B,D,E

Question 29

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.)

a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing.

Answer 29

B,D,E

Question 30

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.)

a. Advanced age
b. Diabetes
c. Ethnic background
d. Medication use
e. Smoking

Answer 30

A,B,C,E