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A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in which way? (Select all that apply.)
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts longer than 15 minutes
- D. Not relieved by rest or nitroglycerin
- E. Triggered by exertion
Correct Answer: A,B,C,D
Rationale: The pain of a myocardial infarction is typically accompanied by shortness of breath, feelings of fear or anxiety, lasts longer than 15 minutes, and is not relieved by rest or nitroglycerin, unlike stable angina. Stable angina is often triggered by exertion, but MI pain can occur at rest.
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Which are modifiable risk factors for coronary artery disease? (Select all that apply.)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
- E. Stress
Correct Answer: B,C,D,E
Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
A nurse is a 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. Teach the client how to use the incentive spirometer.
- 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.
Correct Answer: A,C,E
Rationale: The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs. The incentive spirometer should be used every hour the day after surgery, but teaching is a nursing responsibility. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse for a more detailed assessment.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysparhythmic, and the nurse should be a symptom of the syndrome?
- A. Assess for any hemodynamic effects of the rhythm.
- B. Prepare to administer antidepythymic medication.
- C. Noting the provider or call the Rapid Response Team.
- D. Turn the alarms of on the cardiac monitor.
Correct Answer: A
Rationale: Older clients may have dysparhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysparhythmic before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.
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 titired in the last 4 hours.
- B. Client who is 1 day post coronary artery bypass graft with blood pressure 100/60 mm Hg.
- C. Client with a heart rate of 100 beats/min after angioplasty.
- D. Client with tongue swelling and anxiety post-angioplasty.
Correct Answer: D
Rationale: The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 100 beats/min has increased oxygen demands but is just over the normal limit for heart rate. The two post-coronary artery bypass clients are stable.