Ch. 29- Cardiac
Problems
Problems
Question 1: A nurse is caring for a patient with left-sided heart failure who is receiving enalapril (ACE inhibitor). Which assessment finding requires immediate intervention?
A. Blood pressure 118/76 mm Hg
B. Serum potassium 5.8 mEq/L
C. Heart rate 78 beats/min
D. Respiratory rate 18 breaths/min
Question 2: A patient with heart failure is being discharged on furosemide and lisinopril. The patient reports feeling dizzy when standing up quickly. What is the nurse's best response?
A. "This means your heart failure is worsening."
B. "You should stop taking the lisinopril immediately."
C. "Move slowly when changing positions, especially from lying to sitting."
D. "Increase your fluid intake to 3-4 liters daily."
1. Answer: B
Rationale: ACE inhibitors can cause hyperkalemia, especially in patients with renal dysfunction. A potassium level of 5.8 mEq/L is elevated (normal: 3.5-5.0 mEq/L) and requires immediate intervention to prevent cardiac dysrhythmias. The other vital signs are within normal limits.
2. Answer: C
Rationale: ACE inhibitors like lisinopril can cause orthostatic hypotension. Patients should be taught to move slowly when changing positions to prevent dizziness and falls. This is an expected side effect that can be managed, not a sign of worsening HF. The medication should not be stopped without provider consultation, and excessive fluid intake is contraindicated in HF.
1. A nurse is assessing a patient with a suspected abdominal aortic aneurysm (AAA). Which action should the nurse avoid?
2. A patient with a ruptured AAA arrives in the emergency department. Which assessment findings should the nurse expect? (Select all that apply)
A. Severe sudden back pain
B. Hypertension
C. Decreased level of consciousness
D. Oliguria
E. Bradycardia
1. Answer: B
Rationale: The nurse should NEVER palpate a suspected aneurysm because it may be tender and there is risk for rupture. A pulsation in the upper abdomen slightly to the left of the midline may be visible in aneurysms at least 5 cm in diameter. Auscultating for a bruit is appropriate assessment.
2. Answer: A, C, D
Rationale: Patients with rupturing AAA present with severe pain of sudden onset in the back or lower abdomen. They are critically ill and at risk for hypovolemic shock, manifesting as hypotension (not hypertension), decreased level of consciousness, oliguria, loss of pulses distal to rupture, and dysrhythmias (typically tachycardia, not bradycardia).
A patient in ventricular fibrillation (VF) has just received the first defibrillation shock. High-quality CPR is being performed. Which medication should the nurse prepare to administer next?
A. Magnesium sulfate 2 g IV push
B. Amiodarone 300 mg IV push
C. Epinephrine 1 mg IV push
D. Atropine 0.5 mg IV push
Answer: C. Epinephrine 1 mg IV push
Rationale: Epinephrine should be administered after 2 minutes of CPR in shockable rhythms (VF/pulseless VT) after the first shock has been delivered. Magnesium sulfate is used for refractory VT/VF or torsades de pointes. Amiodarone may be given later in the code. Atropine is not indicated for VF.
A patient with NSTEMI has ST-segment depression and T-wave inversion on ECG. What additional finding confirms myocardial necrosis?
Elevated troponin levels
The combination of ECG changes (ST depression and T-wave inversion) along with elevation of cardiac troponin indicates myocardial cell death or necrosis. Initially troponin may be normal, but it elevates over the next 3 to 12 hours.
A nurse auscultates an S3 gallop in a patient admitted with dyspnea and fatigue. What does this finding indicate?
Early sign of heart failure with increased left ventricular pressure
Rationale: An S3 gallop is an early diastolic filling sound that indicates increased left ventricular pressure and is often the first sign of heart failure. It is not a normal finding and indicates worsening, not resolving, cardiac function.
1. A nurse is teaching a patient with PAD about positioning. Which instruction is correct?
A. "Elevate your legs above heart level to reduce swelling."
B. "Keep your legs in a dependent position below the heart."
C. "Sleep with your legs elevated on two pillows."
D. "Raise your legs whenever you experience pain."
2. Which assessment finding is most indicative of severe PAD?
A. Intermittent claudication after walking five blocks
B. Cold, pulseless extremity with rest pain
C. Warm extremity with 2+ pedal pulses
D. Mild leg cramping relieved by rest
1. Answer: B
Rationale: Patients should avoid raising their legs above the heart level because extreme elevation slows arterial blood flow to the feet. Keeping the limb in a dependent position (below the heart) can help alleviate rest pain by promoting arterial flow through gravity
2. Answer: B
Rationale: Severe PAD presents with rest pain (numb or burning sensation severe enough to awaken patients at night), cold extremities, absent pulses, and may show cyanotic or darkened skin. These patients often have advanced disease that may result in limb loss.
A patient with atrial fibrillation is receiving diltiazem. Which assessment finding requires immediate nursing intervention?
A. Heart rate of 58 beats/min
B. Blood pressure 128/76 mm Hg
C. Respiratory rate of 18 breaths/min
D. Temperature 98.6°F (37°C)
Answer: A. Heart rate of 58 beats/min
Rationale: Diltiazem is a calcium channel blocker used to slow ventricular conduction in AF. Bradycardia is a serious side effect. The nurse must carefully monitor the pulse rate of patients taking these drugs and intervene if the heart rate becomes too slow.
A patient with acute MI develops sinus tachycardia with frequent PVCs. What is the nurse's priority action?
A. Administer antidysrhythmic medication immediately
B. Monitor cardiac rhythm and assess hemodynamic status
C. Prepare for cardioversion
D. Document and continue routine care
Answer: B
Rationale: Dysrhythmias are treated when they cause hemodynamic compromise, increase myocardial oxygen requirements, or predispose the patient to lethal ventricular dysrhythmias. The priority is monitoring cardiac rhythm and hemodynamic status to determine if intervention is needed.
1. A patient is being discharged home with a PICC line for IV antibiotic therapy for infective endocarditis. Which statement by the patient indicates understanding of discharge teaching?
2. Which patient is at highest risk for developing infective endocarditis?
A. 45-year-old with well-controlled hypertension
B. 32-year-old with injection drug use
C. 60-year-old with type 2 diabetes
D. 28-year-old with asthma
1. "I should brush my teeth with a soft toothbrush twice daily."
Rationale: Proper oral hygiene is essential. Patients should use a soft toothbrush and brush at least twice daily. They should NOT floss or use irrigation devices because bacteremia may result. Antibiotics must be taken as scheduled to maintain blood levels, and the full course must be completed.
2. Answer: B
Rationale: Infective endocarditis occurs primarily in patients with injection drug use (IDU), those with valve replacements, systemic immunity alterations, or structural cardiac defects. The incidence is rising with the opioid epidemic.
1. A patient with chronic venous insufficiency has a stasis ulcer on the medial malleolus. Which finding is most characteristic of venous ulcers?
A. Deep, painful ulcer with well-defined borders
B. Shallow ulcer with irregular borders and hyperpigmentation
C. Ulcer with absent pedal pulses
D. Pale, cold extremity with ulceration
2. A patient with DVT asks when they can start walking. What is the nurse's best response?
A. "You must remain on strict bed rest for 7 days."
B. "You can gradually increase ambulation as tolerated."
C. "Walking will dislodge the clot and cause a pulmonary embolism."
D. "You should avoid all activity until the clot dissolves."
1. Answer: B
Rationale: Venous stasis ulcers typically occur over the malleolus (more often medially than laterally) and have irregular borders. Patients with long-term venous insufficiency often have hyperpigmentation in the lower leg and stasis dermatitis. These ulcers are chronic and difficult to heal.
2. Answer: B
Rationale: Research shows that ambulation does not increase the risk for pulmonary embolus. The accepted approach is a gradual increase in ambulation as tolerated by the patient. This may decrease fear and anxiety about clot dislodgment.
A patient received a permanent pacemaker 2 days ago. Which patient statement indicates a need for further teaching?
A. "I'll avoid lifting my arm over my head for 4 weeks"
B. "I should report if my pulse is lower than my pacemaker setting"
C. "I need to keep my microwave unplugged when not in use"
D. "I'll use my cell phone on the opposite side of my pacemaker"
Answer: C. "I need to keep my microwave unplugged when not in use"
Rationale: Current evidence does not include special precautions with common household appliances like microwaves or portable electronics such as radios. However, cellular phones or watches with magnets for wireless charging should be used on the side opposite the pacemaker.
A patient describes chest pain that has been occurring in the past week with increasing frequency and intensity. How should the nurse classify this angina?
Unstable angina
Rationale: Unstable angina represents a change in pattern—increasing frequency, intensity, or occurring at rest. This is part of acute coronary syndrome and requires immediate evaluation. Preinfarction angina refers specifically to chest pain occurring in days or weeks before an MI.
1. A nurse is assessing a patient with acute pericarditis. Which assessment finding is most characteristic of this condition?
A. Chest pain relieved by lying flat
B. Substernal pain that worsens with inspiration
C. Crushing chest pain radiating to the jaw
D. Pain relieved by nitroglycerin
2. The nurse auscultates a high-pitched, scratchy sound at the left lower sternal border in a patient with pericarditis. How should the nurse document this finding?
A. S3 gallop
B. Pericardial friction rub
C. Pleural friction rub
D. Systolic murmur
Answer: B
Rationale: Acute pericarditis causes substernal precordial pain that radiates to the left side of the neck, shoulder, or back. The pain is classically grating and oppressive, aggravated by breathing (mainly on inspiration), coughing, and swallowing. The pain is worse when supine and may be relieved by sitting up and leaning forward—not by lying flat or nitroglycerin.
2. Answer: B
Rationale: A pericardial friction rub is a scratchy, high-pitched sound best heard with the diaphragm of the stethoscope at the left lower sternal border. It's produced when inflamed, roughened pericardial layers create friction as their surfaces rub together.
1. A patient returns from an endovascular intervention for PAD with a femoral artery puncture site. What is the nurse's priority assessment?
A. Bowel sounds and abdominal girth
B. Pedal pulses and extremity temperature
C. Breath sounds and oxygen saturation
D. Level of consciousness and pupil response
2. A patient is prescribed clopidogrel after endovascular stent placement for PAD. What should the nurse teach the patient?
A. "This medication will dissolve any remaining clots."
B. "Take this medication to prevent clotting in your stent."
C. "You'll only need this medication for 48 hours."
D. "This replaces your need for blood pressure medication."
1. Answer: B
Rationale: After endovascular intervention requiring arterial puncture in the groin, the priority is assessing circulation to the affected extremity. Monitor pedal pulses, skin temperature, color, and sensation to detect complications like acute arterial occlusion or bleeding that could compromise perfusion.
2. Answer: B
Rationale: Antiplatelet therapy such as clopidogrel is prescribed after endovascular procedures to prevent arterial clotting and maintain stent patency. Most patients receive anticoagulant or antiplatelet therapy before and/or during the procedure, with continued antiplatelet therapy afterward.
A nurse reviews an ECG strip showing an irregular rhythm with no identifiable P waves, a ventricular rate of 110 beats/min, and a wavy baseline. What dysrhythmia should the nurse suspect?
Answer: B. Atrial fibrillation
Rationale: Atrial fibrillation is characterized by an irregular rhythm with no identifiable P waves and a wavy baseline. The ventricular response can be slow, normal, or rapid. Definitive diagnosis occurs by obtaining a 12-lead ECG.
Which patient is NOT a candidate for thrombolytic therapy?
A. Patient with STEMI and symptom onset 3 hours ago
B. Patient with NSTEMI and elevated troponin
C. Patient with STEMI at a facility without PCI capability
D. Patient with STEMI and no contraindications
Answer: B
Rationale: Thrombolytic therapy is not indicated for the NSTEMI patient population. It is specifically for STEMI patients who cannot receive timely PCI. Thrombolytic therapy dissolves thrombi in the coronary arteries and restores myocardial blood flow.
A patient with heart failure has the following lab results: BUN 45 mg/dL, creatinine 2.1 mg/dL, potassium 3.2 mEq/L. The patient is taking furosemide. What is the nurse's priority action?
A. Continue current medications as ordered
B. Notify the provider about the potassium level
C. Increase the furosemide dose
D. Restrict fluid intake to 1000 mL daily
Answer: B
Rationale: Loop diuretics like furosemide deplete potassium and often cause hypokalemia. A potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L). If serum potassium drops below 4 mEq/L, the provider may prescribe potassium supplements or add a potassium-sparing diuretic. The elevated BUN and creatinine indicate impaired renal function from inadequate perfusion, but the low potassium requires immediate attention to prevent dysrhythmias
A patient returns from open arterial bypass surgery. Which assessment finding is an expected outcome in the first 24 hours?
A. Cool, pale extremity with absent pulses
B. Warmth, redness, and edema of the affected extremity
C. Decreased capillary refill and cyanosis
D. Numbness and tingling in the operative leg
Answer: B
Rationale: Warmth, redness/hyperpigmentation, and edema of the affected extremity are often expected outcomes of surgery as a result of increased arterial perfusion. These findings indicate successful revascularization and improved blood flow to the limb.
A patient's ECG shows a wide QRS complex (0.14 seconds) with seven uniform, rapid ventricular beats at a rate of 180 beats/min. The patient is alert with a blood pressure of 118/72 mm Hg. What intervention should the nurse anticipate?
A. Immediate defibrillation
B. Elective cardioversion
C. Adenosine 6 mg IV push
D. Carotid sinus massage
Answer: B. Elective cardioversion
Rationale: This describes stable ventricular tachycardia. Current ACLS guidelines state that elective cardioversion is recommended for stable VT. Unstable VT without a pulse is treated the same as ventricular fibrillation. The patient is stable with adequate blood pressure.
A patient receives thrombolytic therapy for STEMI. What medication should the nurse expect to administer to maintain coronary artery patency?
A. Oral anticoagulants only
B. Aspirin and IV heparin
C. Beta blockers only
D. Calcium channel blockers
Answer: B
Rationale: After clot lysis with fibrinolytics, large amounts of thrombin are released, increasing the risk for vessel reocclusion. To maintain patency of the coronary artery after thrombolytic therapy, the provider usually prescribes aspirin and IV heparin. The heparin infusion maintains an aPTT between 50 and 70 seconds and is continued for a minimum of 48 hours or until revascularization.