Chest Pressure, Indigestion, and Nausea Flashcards
Ms. S is a 58-year-old African-American woman who is admitted to the coronary care
unit (CCU) from the emergency department (ED) with reports of chest pressure and
indigestion associated with nausea. She started feeling ill about 10 hours before she
called her daughter, who brought her to the ED for admission. She told the nurse that
she tried drinking water and took some bismuth subsalicylate that was in her bathroom
medicine cabinet. She also tried lying down to rest, but none of these actions helped.
She states, “It just gets worse and worse.” Ms. S has been under a health care
provider’s (HCP’s) care for the past 12 years for management of hypertension and
swelling in her ankles. She was a smoker for 43 years but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were
performed, and a 12-lead electrocardiogram (ECG) was taken.
Ms. S’s CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O 2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8°F (37.7°C) (oral)
Which risk factors from Ms. S’s history would suggest a possible cardiac
problem to the nurse? Select all that apply.
1. Hypertension for 12 years
2. Smoked for 43 years; quit smoking 1 year ago
3. Surgery for gallbladder removal 1 year ago
4. Ms. S’s father died at age 42 years from a heart attack
5. Client’s weight is 278 lb (126 kg)
6. Diet includes fast foods three to five times a week
Ans: 1, 2, 4, 5, 6 Risk factors for cardiac problems include hypertension,
family history, obesity, and high-fat diets (which may cause elevation of
cholesterol). Gallbladder surgery would not be a risk factor. Quitting
smoking would be a risk factor, and the years that the client smoked would
be a strong risk factor. Focus: Prioritization.
Which action is best for the nurse to delegate to a new unlicensed assistive
personnel (UAP) orienting to the CCU when caring for Ms. S?
1. Placing the client on a cardiac telemetry monitor
2. Drawing blood to test cardiac marker levels and sending it to the laboratory
3. Obtaining a 12-lead ECG
4. Monitoring and recording the client’s intake and output
Ans: 4 Monitoring and recording intake and output are within the scope of
practice for UAPs. Initiating telemetry, performing venipuncture, and
obtaining ECGs require additional education and training and would not be
delegated to a new UAP. Attaching ECG leads may be done by UAPs in some
facilities, as may venipuncture and ECG recording. However, the UAPs
performing these tasks would require additional specialized training. These
actions are generally considered to be within the scope of practice of licensed
nurses. Focus: Delegation.
Ms. S is a 58-year-old African-American woman who is admitted to the coronary care
unit (CCU) from the emergency department (ED) with reports of chest pressure and
indigestion associated with nausea. She started feeling ill about 10 hours before she
called her daughter, who brought her to the ED for admission. She told the nurse that
she tried drinking water and took some bismuth subsalicylate that was in her bathroom
medicine cabinet. She also tried lying down to rest, but none of these actions helped.
She states, “It just gets worse and worse.” Ms. S has been under a health care
provider’s (HCP’s) care for the past 12 years for management of hypertension and
swelling in her ankles. She was a smoker for 43 years but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were
performed, and a 12-lead electrocardiogram (ECG) was taken.
Ms. S’s CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O 2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8°F (37.7°C) (oral)
Which action prescribed by the HCP for Ms. S takes first priority at this time?
- Measure vital signs every 2 hours.
- Obtain a 12-lead ECG every 6 hours.
- Place the client on a cardiac monitor.
- Check levels of cardiac markers every 6 hours.
. Ans: 3 Cardiac monitoring is the highest priority because the client’s heart
rate is rapid and irregular, and the client is experiencing chest pressure. The
client is at risk for life-threatening dysrhythmias such as frequent premature
ventricular contractions. Measuring vital signs every 2 hours, checking levels
of cardiac markers, and recording a 12-lead ECG every 6 hours are important
to accomplish, but cardiac monitoring takes first precedence. Focus:
Prioritization.
Ms. S is a 58-year-old African-American woman who is admitted to the coronary care
unit (CCU) from the emergency department (ED) with reports of chest pressure and
indigestion associated with nausea. She started feeling ill about 10 hours before she
called her daughter, who brought her to the ED for admission. She told the nurse that
she tried drinking water and took some bismuth subsalicylate that was in her bathroom
medicine cabinet. She also tried lying down to rest, but none of these actions helped.
She states, “It just gets worse and worse.” Ms. S has been under a health care
provider’s (HCP’s) care for the past 12 years for management of hypertension and
swelling in her ankles. She was a smoker for 43 years but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were
performed, and a 12-lead electrocardiogram (ECG) was taken.
Ms. S’s CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O 2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8°F (37.7°C) (oral)
Ms. S’s cardiac telemetry monitor shows a rhythm of sinus tachycardia with
frequent premature ventricular contractions (PVCs). Which drug should the
nurse be prepared to administer first?
1. Amiodarone IV push
2. Nitroglycerin sublingually
3. Morphine sulfate IV push
4. Atenolol IV push
Ans: 1 With frequent PVCs, the client is at risk for life-threatening
dysrhythmias such as ventricular tachycardia or ventricular fibrillation.
Amiodarone is an antidysrhythmic drug used to control ventricular
dysrhythmias. Nitroglycerin and morphine can be given for chest pain relief.
Atenolol is a beta-blocker, which can be used to control heart rate and
decrease blood pressure. Focus: Prioritization; Test Taking Tip: When a
question asks for what to do first or what takes priority, the nurse should
consider what is the most serious danger for the client. In this case, that
danger is related to life-threatening dysrhythmias.
Ms. S is a 58-year-old African-American woman who is admitted to the coronary care
unit (CCU) from the emergency department (ED) with reports of chest pressure and
indigestion associated with nausea. She started feeling ill about 10 hours before she
called her daughter, who brought her to the ED for admission. She told the nurse that
she tried drinking water and took some bismuth subsalicylate that was in her bathroom
medicine cabinet. She also tried lying down to rest, but none of these actions helped.
She states, “It just gets worse and worse.” Ms. S has been under a health care
provider’s (HCP’s) care for the past 12 years for management of hypertension and
swelling in her ankles. She was a smoker for 43 years but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were
performed, and a 12-lead electrocardiogram (ECG) was taken.
Ms. S’s CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O 2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8°F (37.7°C) (oral)
All of these laboratory values were obtained for Ms. S in the emergency
department. Which value would be of most concern to the nurse and have
immediate implications for the care of the client?
1. Potassium level of 3.5 mEq/L (3.5 mmol/L)
2. Troponin T level of more than 0.20 ng/mL (0.2 μg/L)
3. Glucose level of 123 mg/dL (6.83 mmol/L)
4. Slight elevation of white blood cell count
Ans: 2 A troponin T level of more than 0.20 ng/mL (0.2 μg/L) is an elevated
level and indicates myocardial injury or infarction (heart attack). Although
the other laboratory values are all abnormal except the potassium, which is
low normal, none of them is life threatening. The low normal potassium level
would be the second highest concern and might require supplementation to
keep it within normal limits. Remember that hypokalemia can also be a risk
for dysrhythmias. Focus: Prioritization.
Ms. S is a 58-year-old African-American woman who is admitted to the coronary care
unit (CCU) from the emergency department (ED) with reports of chest pressure and
indigestion associated with nausea. She started feeling ill about 10 hours before she
called her daughter, who brought her to the ED for admission. She told the nurse that
she tried drinking water and took some bismuth subsalicylate that was in her bathroom
medicine cabinet. She also tried lying down to rest, but none of these actions helped.
She states, “It just gets worse and worse.” Ms. S has been under a health care
provider’s (HCP’s) care for the past 12 years for management of hypertension and
swelling in her ankles. She was a smoker for 43 years but quit 1 year ago.
In the ED, admission laboratory tests, including levels of cardiac markers, were
performed, and a 12-lead electrocardiogram (ECG) was taken.
Ms. S’s CCU vital sign values on admission are as follows:
Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O 2 saturation 94% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8°F (37.7°C) (oral)
Ms. S tells the nurse that she has worsening chest discomfort. The cardiac
monitor shows ST-segment elevation, and the nurse notifies the HCP. Which
prescribed action takes priority at this time?
1. Administer morphine sulfate 2 mg IV push.
2. Schedule an ECG.
3. Draw blood for coagulation studies.
4. Administer ranitidine 75 mg PO every 12 hours.
Ans: 1 Morphine sulfate has been ordered to relieve the chest discomfort that
is common when a client has an acute myocardial infarction. Relief from the
chest pain is the highest priority at this time. Ranitidine is a histamine 2
blocker used to prevent gastric ulcers. Scheduling an ECG or drawing blood
444for coagulation studies, although important, will not help relieve chest
discomfort. Focus: Prioritization.
Because Ms. S continues to experience chest pain and has elevated levels of
cardiac markers, the following interventions have been prescribed. Which
interventions should the nurse delegate to an experienced UAP? Select all
that apply.
1. Measuring vital signs every 2 hours
2. Accurately recording intake and output
3. Administering tenecteplase IV push
4. Drawing blood for coagulation studies
5. Assessing the cardiac monitor every 4 hours
6. Assisting the client to the bedside commode
Ans: 1, 2, 6 Measuring vital signs, recording intake and output, and assisting
clients with activities of daily living are all within the scope of practice of the
UAP. Administration of IV drugs, venipuncture for laboratory tests, and
assessments are beyond the scope of practice of UAPs and are applicable to
the practice scope of the professional nurse. In some facilities, UAPs may
receive additional training to perform venipuncture, but the RN would need
to assess the UAP’s ability to safely perform this skill before delegation.
Focus: Delegation.
The client is scheduled for an emergent cardiac catheterization with possible
percutaneous coronary intervention (PCI). Ms. S asks the nurse what is
involved with this procedure. What is the nurse’s best response?
1. “It is a procedure that is usually done on clients who have heart attacks to
diagnose blockages in the arteries that feed the heart.”
2. “The cardiologist will use a catheter to inject dye and locate narrowed
arteries, then may inflate a balloon to open the artery and place a stent to
keep it open.”
3. “Cardiac catheterization is usually performed on an outpatient basis to
440determine whether or not you have had a heart attack.”
4. “After the cardiac catheterization, you will come back to the coronary care
unit, where you will be on bed rest for 6 to 8 hours, and we will check your
vital signs often.”
Ans: 2 The nurse’s best response should be attentive to and answer the client’s
question. For the cardiac catheterization, the client is taken to a special lab
where the cardiologist uses an invasive catheter with injectable dye to locate
and diagnose narrowed sections of coronary arteries. For percutaneous
coronary intervention, a catheter is placed with a balloon, which can be
inflated to open the narrowed section, and a stent (an expandable metal mesh
device) can be left in place to keep the artery opened. Options 1, 3, and 4 do
not accurately answer the client’s question about the procedure. Focus:
Prioritization.
Ms. S has returned from a cardiac catheterization and a percutaneous
coronary intervention procedure. Which follow-up care orders should the
nurse assign to an experienced LPN/LVN? Select all that apply.
1. Reminding the client to remain on bed rest with the insertion site extremity
straight
2. Preparing a teaching plan that includes activity restrictions and risk factor
modification
3. Measuring the client’s vital signs every 15 minutes for the first hour
4. Assessing the catheter insertion site for bleeding or hematoma formation
5. Monitoring peripheral pulses, skin temperature, and skin color with each
measurement of vital signs
6. Administering two tablets of acetaminophen for back pain
Ans: 1, 3, 4, 5, 6 All of these interventions are within the scope of practice of
an experienced LPN/LVN. The LPN/LVN would be instructed when to notify
the RN or the HCP of any abnormal findings. Preparing a teaching plan
requires additional education and is more suited to the RN’s scope of
practice. Taking vital signs and reminding the client about bed rest could also
be delegated to the UAP. Focus: Assignment, Supervision.
Which information is most important to prevent recurrence of reocclusion of
the coronary artery, chest discomfort, or myocardial infarction (MI)?
1. Remain on bed rest for the next 24 hours.
2. Client will be prescribed dual antiplatelet therapy (DAT).
3. Client should do no heavy lifting for 48 hours.
4. HCP will prescribe a beta-blocker.
Ans: 2 Without stent placement, the artery often reoccludes due to the
artery’s normal elasticity and memory. Clients who undergo percutaneous
coronary intervention are required to take DAT consisting of aspirin and a
platelet inhibitor to prevent recurrence of artery blockage, chest pain, and MI.
Clients are not kept on bed rest for 24 hours; rather, they are instructed to do
no heavy lifting for several days after this procedure, and they are often
prescribed a beta-blocker to slow heart rate and lower blood pressure. Focus:
Prioritization.
Ms. S’s daughter asks the nurse why her mother did not receive a “clot-
buster” drug. What is the nurse’s best response?
1. “Thrombolytic agents, also called clot busters, are most effective when
administered within the first 6 hours of a coronary event.”
2. “Thrombolytic drugs are much more effective when used for clients who
have had a recent stroke.”
3. “Thrombolytic drugs work better for clients who have a heart attack at a
much younger age.”
4. “Contraindications for these drugs include recent surgeries, and your
mother had gallbladder surgery a year ago.”
Ans: 1 Thrombolytic therapy using fibrinolytics dissolves thrombi in the
coronary arteries and restores myocardial blood flow. Intracoronary
fibrinolytics may be delivered during cardiac catheterization. Thrombolytic
agents are most effective when administered within the first 6 hours of a
coronary event. They are used in men and women, young and old. Focus:
Prioritization.
Ms. S’s condition is stable, and she has been transferred to the cardiac step-
down unit. What should the step-down nurse instruct the UAP to report
immediately?
1. Temperature of 99°F (37.2°C) with morning vital sign monitoring
2. Chest pain episode occurring during morning care
3. Systolic blood pressure increase of 8 mm Hg after morning care
4. Heart rate increase of 10 beats/min after ambulation
Ans: 2 Chest pain can be an indicator of additional myocardial muscle
damage. Additional episodes of chest pain significantly affect the client’s plan
of care. Small increases in heart rate and blood pressure after activity are to
be expected. The client’s temperature, only 0.2°F (0.1°C) higher than at
445admission, is not a priority at this time. Focus: Prioritization, Delegation,
Supervision.
The nurse delegates to the UAP the task of taking Ms. S’s vital signs every 4
441hours and recording the vital sign values in the electronic chart. Later the
nurse checks the client’s chart and discovers that vital sign measurements
have not been recorded. What is the nurse’s best action?
1. Take the vital signs because the UAP is not competent to complete this task.
2. Notify the nurse manager immediately.
3. Reprimand the UAP at the nurses’ station.
4. Speak to the UAP privately to determine why the values were not
recorded.
Ans: 4 Measuring and recording vital sign values are within the scope of
practice of the UAP. When the UAP makes a mistake, it is best to
communicate specifically, stressing the importance of recording vital sign
values after they have been obtained. Supervision should be done in a
supportive rather than confrontational manner. Notifying the nurse manager
is not appropriate at this time. Reprimanding the UAP in front of others also
is not appropriate. Focus: Delegation, Supervision.
The HCP prescribes captopril 12.5 mg orally twice daily and
hydrochlorothiazide (HCTZ) 25 mg orally daily. Which information would
the nurse be sure to include when teaching Ms. S about these drugs?
1. “Take your hydrochlorothiazide in the morning.”
2. “If you miss a dose of captopril, take two tablets next time.”
3. “Avoid foods that are rich in potassium, such as bananas and oranges.”
4. “You should expect an increase in blood pressure with these drugs.”
Ans: 1 HCTZ is a thiazide diuretic used to correct edema and lower blood
pressure, and it should be taken in the morning so that its diuretic effects do
not keep the client up during the night. A side effect of HCTZ is loss of
potassium, and clients may require potassium supplementation. Captopril is
an angiotensin-converting enzyme inhibitor that lowers blood pressure. It is
never appropriate to take twice the dose of this drug. Focus: Prioritization.
The HCP orders DAT for Ms. S. What is the nurse’s priority concern for this
client?
1. Reminding the client to do no heavy lifting while hospitalized
2. Assessing the progression of walking in the halls
3. Teaching the client to apply oxygen for any shortness of breath
4. Monitoring the client for any form of bleeding
Ans: 4 DAT is suggested for all clients with acute coronary syndrome,
incorporating aspirin and either clopidogrel or ticagrelor. The major side
effect for each of these agents is bleeding. Observe for bleeding tendencies,
such as nosebleeds or blood in the stool. Medications will need to be
discontinued if evidence of bleeding occurs. Focus: Prioritization; Test
Taking Tip: With DAT, the client is prescribed two drugs that increase the
risk for bleeding, so bleeding is the priority assessment when a client is
prescribed this therapy.
