Chapter 38: Care of Patients with Acute Coronary Syndromes Ignatavicius: Medical-Surgical Nursing, 8th Edition

Question 1

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?
   a. Assess the clients pupillary responses.
   b. Request a neurologic consultation.
   c. Stop the infusion and call the provider.
   d. Take and document a full set of vital signs.

Answer 1

c. Stop the infusion and call the provider.

Question 2

2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best?
   a. The t-PA didnt dissolve the entire coronary clot.
   b. The heparin keeps that artery from getting blocked again.
   c. Heparin keeps the blood as thin as possible for a longer time.
   d. The heparin prevents a stroke from occurring as the t-PA wears off

Answer 2

b. The heparin keeps that artery from getting blocked again.

Question 3

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 clients 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?
   a. Administer oxygen at 2 L/min.
   b. Allow continued bathroom privileges.
   c. Obtain a bedside commode.
   d. Suggest the client use a bedpan.

Answer 3

b. Allow continued bathroom privileges.

Question 4

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?
   a. Continue to educate the client on possible healthy changes.
   b. Emphasize complications that can occur with noncompliance.
   c. Tell the client that denial is normal and will soon go away.
   d. You need to make sure the client understands this illness.

Answer 4

a. Continue to educate the client on possible healthy changes.

Question 5

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?
   a. Level the transducer at the phlebostatic axis.
   b. Lay the client in the supine position.
   c. Prepare to administer diuretics.
   d. Prepare to administer a fluid bolus.

Answer 5

d. Prepare to administer a fluid bolus.

Question 6

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?
   a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends.
   b. Ensure the balloon does not remain wedged.
   c. Keep the client on strict NPO status.
   d. Maintain the client in a semi-Fowlers position.

Answer 6

b. Ensure the balloon does not remain wedged.

Question 7

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients 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?
   a. Allow the client to rest quietly.
   b. Assess the client for bleeding.
   c. Document the findings in the chart.
   d. Medicate the client for pain.

Answer 7

b. Assess the client for bleeding.

Question 8

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?
   a. Ask the family members to wait in the waiting area.
   b. Inform the client that this behavior is unacceptable.
   c. Stay out of the room to decrease the clients stress levels.
   d. Tell the client that anxiety is common and that you can help.

Answer 8

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

Question 9

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?
   a. Do you have any concerns about sexuality?
   b. Im glad to hear you are sleeping well now.
   c. Sleep near your spouse in case of emergency.
   d. Why would you move into the guest room?

Answer 9

a. Do you have any concerns about sexuality?

Question 10

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?
    a. Administer an aspirin.
    b. Call for an electrocardiogram (ECG).
    c. Maintain airway patency.
    d. Notify the provider.
    ANS: C

Answer 10

c. Maintain airway patency.

Question 11

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?
    a. Assess for any hemodynamic effects of the rhythm.
    b. Prepare to administer antidysrhythmic medication.
    c. Notify the provider or call the Rapid Response Team.
    d. Turn the alarms off on the cardiac monitor.

Answer 11

a. Assess for any hemodynamic effects of the rhythm.

Question 12

12. The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
    a. Assess vital signs.
    b. Don a mask and gown.
    c. Gather needed supplies.
    d. Perform hand hygiene.

Answer 12

d. Perform hand hygiene.

Question 13

13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first?
    a. Assess the insertion site.
    b. Change the clients sheets.
    c. Put on a pair of gloves.
    d. Assess blood pressure.

Answer 13

c. Put on a pair of gloves.

Question 14

14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
    a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
    b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
    c. Client who is 1 day post percutaneous coronary intervention, going home this morning
    d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Answer 14

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

Question 15

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?
    a. Fish oil is contraindicated with most drugs for CAD.
    b. The best source is fish, but pills have benefits too.
    c. There is no evidence to support fish oil use with CAD.
    d. You can reverse CAD totally with diet and supplements.

Answer 15

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

Question 16

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 Commissions Core Measures outcomes?
    a. Obtain an electrocardiogram (ECG) now and in the morning.
    b. Give the client an aspirin.
    c. Notify the Rapid Response Team.
    d. Prepare to administer thrombolytics.

Answer 16

b. Give the client an aspirin.

Question 17

17. A nurse is caring for four clients. Which client should the nurse assess first?
    a. Client with an acute myocardial infarction, pulse 102 beats/min
    b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
    c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
    d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

Answer 17

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

Question 18

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?
    a. Allow family members to remain at the bedside.
    b. Ask the family if the client would like a fan in the room.
    c. Keep the television tuned to the clients favorite channel.
    d. Speak loudly to the client in case of hearing problems.

Answer 18

a. Allow family members to remain at the bedside.

Question 19

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?
    a. Increase the setting on the suction.
    b. Notify the provider immediately.
    c. Re-position the chest tube.
    d. Take the tubing apart to assess for clots.

Answer 19

b. Notify the provider immediately.

Question 20

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?
    a. Dirty carpets in need of vacuuming
    b. Expired food in the refrigerator
    c. Old medications in the kitchen
    d. Several cats present in the home

Answer 20

b. Expired food in the refrigerator

Question 21

21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
    a. Assess the IV site hourly.
    b. Monitor the pedal pulses.
    c. Monitor the clients vital signs.
    d. Obtain consent for a central line.

Answer 21

a. Assess the IV site hourly.

Question 22

22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
    a. Blood pressure that is 20 mm Hg below baseline
    b. Oxygen saturation of 94% on room air
    c. Poor peripheral pulses and cool skin
    d. Urine output of 1.2 mL/kg/hr for 4 hours

Answer 22

c. Poor peripheral pulses and cool skin

Question 23

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 Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
    a. 1530 (3:30 PM)
    b. 1600 (4:00 PM)
    c. 1630 (4:30 PM)
    d. 1700 (5:00 PM)

Answer 23

c. 1630 (4:30 PM)

Question 24

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?
    a. It constricts vessels, improving blood flow.
    b. It dilates vessels, which lessens the work of the heart.
    c. It increases the force of the hearts contractions.
    d. It slows the heart rate down for better filling.

Answer 24

c. It increases the force of the hearts contractions.

A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.

Question 25

25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate?
    (Click the media button to hear the audio clip.)
    a. Assess for further chest pain.
    b. Call the Rapid Response Team.
    c. Have the client sit upright.
    d. Listen to the clients lung sounds.

Answer 25

d. Listen to the clients lung sounds.

Question 26

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

What action by the nurse is most important?

a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication.

Answer 26

a. Assess the clients blood pressure and level of consciousness.

Question 27

1. 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. Smokinge.
   e. Stress

Answer 27

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

Question 28

2. 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 28

a. Assist the client to the chair for meals and to the bathroom.
c. Ensure the client wears TED hose or sequential compression devices.
e. Take and record a full set of vital signs per hospital protocol.

Question 29

3. 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 29

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

Question 30

4. 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 30

b. Assist the client into a position of comfort in bed.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing.

Question 31

5. 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 31

a. Advanced age
b. Diabetes
c. Ethnic background
e. Smoking