Care Of Patients With Acute Coronary Syndrome

1.

A client who had thrombolytic therapy is receiving a continuous infusion of sodium heparin. In the past hour, the client’s blood pressure changed from 122/74 to 98/46 mm Hg. His pulse is rapid and weak. What is the nurse’s first action at this time?

A.

Assess for signs of bleeding
B.

Slow the heparin infusion rate
C.

Document the blood pressure change
D.

Stop the heparin infusion immediately

Correct Answer
D. Stop the heparin infusion immediately

Explanation
p. 840, Physiological Integrity
Based on the assessment data, the nurse’s first action should be to stop the heparin infusion, because the change in vital signs is consistent with bleeding. Heparin is an anticoagulant and increases the client’s risk for bleeding. The client may be bleeding internally, so symptoms of bleeding on assessment may not be overt. Simply decreasing the infusion rate will still lead to anticoagulation of the blood and increase the client’s risk for further bleeding. Documentation is always an important nursing action but, in this case of suspected bleeding, documentation can wait until after the heparin infusion is stopped.

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2.

A client had a coronary artery bypass graft 2 days ago and has a new onset of atrial fibrillation. What diagnostic test will the nurse check that could explain this dysrhythmia?

A.

Arterial oxygen level
B.

Serum potassium
C.

Serum sodium
D.

Blood urea nitrogen

Correct Answer
B. Serum potassium

Explanation
p. 849, Physiological Integrity
Hypokalemia after a coronary artery bypass graft procedure is a common cause of atrial fibrillation. Other complications may also include hypotension, hypothermia, hypertension, bleeding, cardiac tamponade, decreased level of consciousness, and anginal pain. Studies remain inconclusive on the role sodium plays in the development of atrial fibrillation. Elevated blood urea nitrogen levels may occur related to dehydration or decreased cardiac perfusion but have no connection to the development of atrial fibrillation.

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3.

Your patient is a 47-year-old woman who presents to the emergency department with complaints of sudden onset of mid-sternal chest pain radiating to her right arm, nausea, and profuse sweating for the past hour. Her past medical history is unremarkable for cardiac disease. She had abdominal surgery 1 month ago to remove her spleen. She is given a total of three sublingual nitroglycerin tablets without relief and is receiving an IV infusion of nitroglycerin. The team is now considering administering tissue plasminogen activator (t-PA). Her laboratory work and electrocardiogram (ECG) confirm the diagnosis of myocardial infarction. Which parameter will be most affected when administering nitroglycerin?

A.

Heart Rate
B.

Blood Pressure
C.

Heart Rhythm
D.

Respiratory Rate

Correct Answer
B. Blood Pressure

Explanation
p. 861 The blood pressure is continuously monitored. Refer also to Chart 40-5. Nitrates cause general vasodilation, and a decrease in blood pressure occurs with vasodilation.

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4.

An older client has a history of stable angina. Which modifiable risk factors will the nurse assess to guide the client’s teaching plan? Select all that apply.

A.

Older Age
B.

Tobacco use
C.

Activity level
D.

Serum lipid levels
E.

Family history
F.

Weight

Correct Answer(s)
B. Tobacco use
C. Activity level
D. Serum lipid levels
F. Weight

Explanation
p. 834, Health Promotion and Maintenance. \

Modifiable risk factors are lifestyle choices that can be controlled by the client, such as smoking, activity level, control of serum lipid levels, and control of obesity through dietary management. Nonmodifiable risk factors are personal characteristics that cannot be altered or controlled. These risk factors, which interact with each other, include age, gender, family history, and ethnic background.

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5.

A client with chronic stable angina receives discharge teaching from the nurse. Which statement by the client indicates a need for further teaching?

A.

“I need to take my nitroglycerin tablets to prevent any serious problems.”
B.

“At the first sign of chest discomfort, I will stop any activity and sit down.”
C.

“I will call 911 if my chest discomfort continues after taking 3 nitroglycerin tablets.”
D.

“I understand I must follow up with my health care provider regularly.”

Correct Answer
A. “I need to take my nitroglycerin tablets to prevent any serious problems.”

Explanation
Nitroglycerin should be taken at the first sign of chest discomfort. Nitroglycerin increases collateral blood flow, dilates the coronary arteries, and redistributes the blood flow toward the subendocardium. It also decreases both preload and afterload by decreasing myocardial oxygen demand through peripheral vasodilation.
B is incorrect. If rest does not provide relief for the chest pain, the client may need to take nitroglycerin.
C is incorrect. If the nitroglycerin does not relieve the chest discomfort after 3 tablets, the client needs to be immediately transported to a hospital where further evaluation and monitoring to rule out an MI are possible.
D is incorrect. Continued supervision by a health care provider is necessary to monitor progress of coronary heart disease to prevent complications and provide support.

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6.

After receiving the change-of-shift report, which client should the nurse assess first? The client with:

A.

Stable angina who had chest pain relieved with two nitroglycerin tablets 1 hour ago
B.

Unstable angina having substernal chest pain, nausea, sweating, and anxiety.
C.

Stable vital signs who returned from the percutaneous coronary intervention lab 30 minutes ago.
D.

N acute MI transferred from the coronary care unit earlier today reporting a headache

Correct Answer
B. Unstable angina having substernal chest pain, nausea, sweating, and anxiety.

Explanation
p. 869 Rationale: These are symptoms of a possible acute MI and need to be immediately assessed and interventions started to prevent further complications and possibly death.
A is incorrect. If the nitroglycerin relieved the chest pain, this client would not be a priority for evaluation.
C is incorrect. The client was most likely monitored postprocedure in the percutaneous coronary intervention lab before being transferred with stable vital signs. This client should be checked for signs of site bleeding as soon as possible.
D is incorrect. The headache can have many causes, including medication, stress, or fatigue. An assessment should be done and intervention implemented to alleviate the headache.

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7.

The nurse is assessing the client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI?

A.

Chest pain brought on by exertion or stress
B.

Substernal chest discomfort not relieved by rest
C.

Substernal chest discomfort relieved by nitroglycerin or rest
D.

Substernal chest pressure relived only by opioids

Correct Answer
D. Substernal chest pressure relived only by opioids

care Of Patients With Acute Coronary Syndrome

A client who had thrombolytic therapy is receiving a continuous infusion of sodium heparin. In the past hour, the client’s blood pressure changed from 122/74 to 98/46 mm Hg. His pulse is rapid and weak. What is the nurse’s first action at this time?

A client had a coronary artery bypass graft 2 days ago and has a new onset of atrial fibrillation. What diagnostic test will the nurse check that could explain this dysrhythmia?

An older client has a history of stable angina. Which modifiable risk factors will the nurse assess to guide the client’s teaching plan? Select all that apply.

A client with chronic stable angina receives discharge teaching from the nurse. Which statement by the client indicates a need for further teaching?

After receiving the change-of-shift report, which client should the nurse assess first? The client with:

The nurse is assessing the client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI?