Nokea
The nurse is caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having percutaneous coronary intervention and the nurse obtains these assessment data. Which of the following data indicate the need for immediate intervention by the nurse?
- A. Pedal pulses 1+
- B. Heart rate 100 beats/minute
- C. Blood pressure 104/56 mm Hg
- D. Chest pain level 8 on a 10-point scale
Correct Answer: D
Rationale: The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.
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The nurse is caring for a patient who has had severe chest pain for several hours and a diagnosis of possible acute myocardial infarction. Which of the following prescribed laboratory tests should the nurse monitor to help determine the diagnosis?
- A. Homocysteine
- B. C-reactive protein
- C. Cardiac-specific troponin
- D. High-density lipoprotein (HDL) cholesterol
Correct Answer: C
Rationale: Troponin levels increase about 3-12 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.
The nurse is providing teaching to a patient about use of sublingual nitroglycerin. Which of the following patient statements indicates that the teaching has been effective?
- A. I will put the nitroglycerin tablet under my tongue if I get chest pain.
- B. I like fresh salmon and I will plan to eat it more often.
- C. I will miss being able to eat peanut butter sandwiches.
- D. I can have a cup of coffee with breakfast if I want one.
Correct Answer: A
Rationale: Sublingual nitroglycerin is taken by placing the tablet under the tongue to relieve chest pain. The other statements relate to dietary preferences and do not indicate understanding of nitroglycerin use.
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.
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.
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.