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The nurse is administering IV nitroglycerin to a patient with a myocardial infarction (MI). Which of the following actions should the nurse take to evaluate the effectiveness of the medication?
- A. Check blood pressure.
- B. Monitor apical pulse rate.
- C. Monitor for dysrhythmias.
- D. Ask about chest discomfort.
Correct Answer: D
Rationale: The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.
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Which of the following information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction?
- A. The pain increases with deep breathing.
- B. The pain has persisted longer than 30 minutes.
- C. The pain worsens when the patient raises the arms.
- D. The pain is relieved after the patient takes nitroglycerin.
Correct Answer: B
Rationale: Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial infarction. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin.
The nurse is caring for a patient with angina who has been prescribed propranolol. Which of the following parameters should the nurse assess to determine whether the drug is effective?
- A. Decreased blood pressure and apical pulse rate
- B. Fewer complaints of having cold hands and feet
- C. Improvement in the quality of the peripheral pulses
- D. The ability to do daily activities without chest discomfort
Correct Answer: D
Rationale: Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The non-cardioselective β-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature.
To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of the following nursing interventions will be most effective?
- A. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.
- B. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.
- C. Assist the patient to modify favourite high-fat recipes by using polyunsaturated oils when possible.
- D. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.
Correct Answer: C
Rationale: Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.
Which of the following information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?
- A. No change in the patient's chest pain
- B. A large bruise at the patient's IV insertion site
- C. A decrease in ST segment elevation on the electrocardiogram (ECG)
- D. An increase in cardiac enzyme levels since admission
Correct Answer: A
Rationale: Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible adverse effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened.
The nurse is admitting a patient with a myocardial infarction (MI) to the intensive care unit. Which of the following actions should the nurse carry out first?
- A. Obtain the blood pressure.
- B. Attach the cardiac monitor.
- C. Assess the peripheral pulses.
- D. Auscultate the breath sounds.
Correct Answer: B
Rationale: Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.