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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.
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The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction 2 days previously. Which of the following information is most important to report to the health care provider?
- A. The patient denies ever having a heart attack
- B. The cardiac-specific troponin level is elevated.
- C. The patient has occasional premature atrial contractions (PACs)
- D. Crackles are auscultated bilaterally in the mid-lower lobes.
Correct Answer: D
Rationale: The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.
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 caring for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) who is receiving heparin. Which of the following information explains the purpose of the heparin?
- A. Platelet aggregation is enhanced by IV heparin infusion.
- B. Heparin will dissolve the clot that is blocking blood flow to the heart.
- C. Coronary artery plaque size and adherence are decreased with heparin.
- D. Heparin will prevent the development of new clots in the coronary arteries.
Correct Answer: D
Rationale: Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.
A patient with ST segment elevation in several electrocardiogram (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which of the following questions should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy?
- A. Do you take Aspirin on a daily basis?
- B. What time did your chest pain begin?
- C. Is there any family history of heart disease?
- D. Can you describe the quality of your chest pain.
Correct Answer: B
Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information also will be needed, but it will not be a factor in the decision about fibrinolytic therapy.
The nurse will suspect that the patient with stable angina is experiencing an adverse effect of the prescribed metoprolol if which of the following findings are assessed?
- A. The patient is restless and agitated.
- B. The blood pressure is 190/110 mm Hg.
- C. The patient complains about feeling anxious.
- D. The cardiac monitor shows a heart rate of 45.
Correct Answer: D
Rationale: Patients taking β-adrenergic blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be adverse effects.