General Cardiac
A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to:
a. ask for assistance when getting out of bed.
b. expect bradycardia for a few days.
c. notify the provider if headache occurs.
d. report shortness of breath.
ANS: A
A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects.
A nurse is caring for a patient with chronic hypertension who also has a history of asthma. Which class of antihypertensive medication should the nurse question if prescribed?
A. ACE inhibitors
B. Calcium channel blockers
C. Non-selective beta blockers
D. Angiotensin receptor blockers (ARBs)
ANS: C
Non-selective beta blockers affect both beta 1 (heart) and beta 2 (lungs) receptors. Blocking beta 2 receptors can cause bronchoconstriction, which is especially dangerous in patients with asthma.
A patient is taking enalapril (Vasotec). The nurse understands that patients taking this type of drug for heart failure need to be monitored carefully for:
a. hypernatremia.
b. hypertension.
c. hyperkalemia.
d. hypokalemia.
ANS: C
One of the principal effects of angiotensin-converting enzyme (ACE) inhibitors is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II. There is no indication that careful monitoring of sodium for increased levels is indicated. Vasotec is indicated for heart failure, not hypertension. The drug therapy should be monitored to ascertain its effectiveness, but hyperkalemia is the main concern. Hyperkalemia, not hypokalemia, is a concern because of the decreased aldosterone release that occurs with blockage of angiotensin II.
A patient with atrial fibrillation is taking verapamil (Calan). The patient has read about the drug on the Internet and wants to know why a drug that affects the rate of ventricular contraction is used to treat an abnormal atrial contraction. What will the nurse tell the patient?
a. “Drugs that treat ventricular dysrhythmias help to restore normal sinus rhythm.”
b. “Atrial dysrhythmias can have life-threatening effects on ventricular function.”
c. “Treating ventricular dysrhythmias helps prevent the likelihood of stroke.”
d. “When ventricular contraction slows, atrial contraction is also slowed.”
ANS: B
Dysrhythmic activity in the atria does not significantly reduce cardiac output but can be dangerous when dysrhythmic impulses cross the AV node, causing ventricular dysrhythmias, which can be life threatening. Treating ventricular dysrhythmia helps improve ventricular pumping. These drugs do not restore normal sinus rhythm. To prevent stroke, an anticoagulant, such as warfarin, is used. Slowing ventricular contraction does not affect the rate of atrial contraction. Restoring normal sinus rhythm requires cardioversion, short-term treatment with amiodarone or sotalol, or RF ablation of the dysrhythmia source.
A patient asks a nurse how nitroglycerin works to relieve anginal pain. The nurse correctly states, “Nitroglycerin:
a. dilates coronary arteries to increase blood flow to the heart.”
b. increases the oxygen supply to the cardiac muscle.”
c. increases ventricular filling to improve cardiac output.”
d. promotes vasodilation, which reduces preload and oxygen demand.”
ANS: D
Nitroglycerin dilates the veins, which reduces venous return to the heart, which in turn decreases ventricular filling. The resulting decrease in preload reduces the oxygen requirements of the heart. Nitroglycerin does not increase the blood flow or oxygen supply to the heart. An increase in ventricular filling would increase oxygen demand and result in increased anginal pain.
A patient with a history of hypertension is admitted for a procedure. If the patient’s arterial pressure decreases, which clinical manifestation would the nurse expect to see?
a. Decreased heart rate
b. Increased heart rate
c. Decreased blood pressure
d. Syncope
ANS: B
When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope.
A female patient taking an ACE inhibitor learns that she is pregnant. What will the nurse tell this patient?
a. The fetus most likely will have serious congenital defects.
b. The fetus must be monitored closely while the patient is taking this drug.
c. The patient’s prescriber probably will change her medication to an ARB.
d. The patient should stop taking the medication and contact her provider immediately.
ANS: D
ACE inhibitors are known to cause serious fetal injury during the second and third trimesters of pregnancy. Whether injury occurs earlier in pregnancy is unknown, and the incidence probably is low. However, women should be counseled to stop taking the drug if they become pregnant, and they should not take it if they are contemplating becoming pregnant. Women who take ACE inhibitors in the first trimester should be counseled that the risk to the fetus is probably low. Women should stop taking the drug when pregnant. ARBs carry the same risk as ACE inhibitors.
A nurse is discussing heart failure with a group of nursing students. Which statement by a student reflects an understanding of how compensatory mechanisms can compound existing problems in patients with heart failure?
a. “An increase in arteriolar tone to improve tissue perfusion can decrease resistance.”
b. “An increase in contractility to increase cardiac output can cause pulmonary edema.”
c. “When the heart rate increases to increase cardiac output, it can prevent adequate filling of the ventricles.”
d. “When venous tone increases to increase ventricular filling, an increase in arterial pressure occurs.”
ANS: C
The heart rate increases to improve cardiac output, but it may prevent adequate ventricular filling. An increase in arteriole tone improves tissue perfusion but also increases both the resistance to the pumping of the heart and the cardiac workload. Increased contractility helps improve cardiac output but is detrimental because it increases the oxygen demand of the heart. An increase in venous tone improves ventricular filling but, as the ventricles fail, blood can back up and cause pulmonary edema.
A nurse is teaching a group of nursing students about antidysrhythmic medications. Which statement by a student indicates understanding of the teaching?
a. “Antidysrhythmic drugs can cause new dysrhythmias or worsen existing ones.”
b. “Adverse effects of these drugs are mainly noncardiac in nature.”
c. “For most antidysrhythmic drugs, there is evidence of reduced mortality.”
d. “Use of these drugs may be necessary even if the benefits are unknown.”
ANS: A
Because antidysrhythmic drugs have prodysrhythmic actions, they can exacerbate existing dysrhythmias or generate new ones. Most adverse effects are cardiac related. There is evidence of increased mortality with many of these drugs. Use of these drugs should be limited to situations in which there is a clear benefit and only if that benefit outweighs any risks.
A hospitalized patient complains of acute chest pain. The nurse administers a 0.3 mg sublingual nitroglycerin tablet, but the patient continues to complain of pain. Vital signs remain stable. What is the nurse’s next step?
a. Apply a nitroglycerin transdermal patch.
b. Continue dosing at 10-minute intervals.
c. Give a second dose of nitroglycerin in 5 minutes.
d. Request an order for intravenous nitroglycerin.
ANS: C
An initial dose of sublingual nitroglycerin is taken, and if the chest pain persists, as in this case, the patient should take another dose in 5 minutes. Transdermal delivery systems are not useful for terminating an ongoing attack. Dosing at 10-minute intervals is incorrect. If the patient fails to respond or if the pain intensifies, intravenous nitroglycerin may be indicated.
A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug?
a. Decreased stroke volume
b. Increased stroke volume
c. Decreased myocardial contractility
d. Increased myocardial contractility
ANS: A
Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1-adrenergic receptors in the myocardium.
A patient begins taking nifedipine (Procardia), along with a beta blocker, to treat hypertension. The nurse understands that the beta blocker is used to:
a. reduce flushing.
b. minimize gingival hyperplasia.
c. prevent constipation.
d. prevent reflex tachycardia.
ANS: D
Beta blockers are combined with nifedipine to prevent reflex tachycardia. Beta blockers do not reduce flushing, minimize gingival hyperplasia, or prevent constipation. Beta blockers can reduce the adverse cardiac effects of nifedipine.
A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats per minute, a blood pressure of 150/90 mmHg, bibasilar crackles, 2+ pitting edema of the ankles, and distension of the jugular veins. The nurse will contact the provider to request an order for which medication?
a. ACE inhibitor
b. Digoxin (Lanoxin)
c. Furosemide (Lasix)
d. Spironolactone (Aldactone)
ANS: C
This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a high-ceiling (loop) diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.
A prescriber has ordered propranolol (Inderal) for a patient with recurrent ventricular tachycardia. The nurse preparing to administer this drug will be concerned about what in the patient’s history?
a. Asthma
b. Exercise-induced tachyarrhythmias
c. Hypertension
d. Paroxysmal atrial tachycardia associated with emotion
ANS: A
Propranolol is contraindicated in patients with asthma, because it is a nonselective beta-adrenergic antagonist and can cause bronchoconstriction and exacerbate asthma. It is used to treat tachyarrhythmias and paroxysmal atrial tachycardia evoked by emotion, so it is not contraindicated for patients with these conditions. It lowers blood pressure, so it would be helpful in patients with hypertension.
A nursing student asks a nurse how beta blockers increase the oxygen supply to the heart in the treatment of anginal pain. The nurse tells the student that beta blockers:
a. dilate arterioles to improve myocardial circulation.
b. improve cardiac contractility, which makes the heart more efficient.
c. increase arterial pressure to improve cardiac afterload.
d. increase the time the heart is in diastole.
ANS: D
Beta blockers increase the time the heart is in diastole, which increases the time during which blood flows through the myocardial vessels, allowing more oxygen to reach the heart. Beta blockers do not dilate arterioles. They do not increase cardiac contractility; they decrease it, which reduces the cardiac oxygen demand. They do not increase arterial pressure, which would increase the cardiac oxygen demand.
A nurse is educating a patient newly diagnosed with chronic hypertension about the role of the kidneys in blood pressure regulation. The nurse correctly explains that when blood flow to the kidneys decreases due to narrowed vessels, the kidneys respond by:
A. Increasing renin secretion, which further elevates blood pressure
B. Decreasing renin secretion to lower blood pressure
C. Increasing sodium excretion to reduce blood pressure
D. Slowing heart rate to compensate for high blood pressure
ANS: A
When the kidneys experience reduced blood flow due to narrowed vessels from chronic hypertension, they compensate by increasing renin secretion, which activates the renin-angiotensin-aldosterone system (RAAS) and ultimately increases blood pressure, creating a harmful cycle.
A nurse is administering a vasodilator that dilates resistance vessels. The nurse understands that this drug will have which effect on the patient?
a. Decreased cardiac preload
b. Decreased cardiac output
c. Increased tissue perfusion
d. Increased ventricular contraction
ANS: C
Vasodilators that dilate resistance vessels, or arterioles, cause a decrease in afterload, which allows cardiac output and tissue perfusion to increase. A decrease in preload would be the result of dilation of capacitance vessels, or veins. Dilation of arterioles increases cardiac output. Ventricular contraction results when preload is increased.
A nurse prepares to administer a scheduled dose of digoxin. The nurse finds a new laboratory report showing a plasma digoxin level of 0.7 ng/mL. What action should the nurse take?
a. Withhold the drug for an hour and reassess the level.
b. Withhold the drug and notify the prescriber immediately.
c. Administer Digibind to counteract the toxicity.
d. Check the patient’s apical pulse, and if it is within a safe range, administer the digoxin.
ANS: D
The optimum plasma digoxin range is 0.5 to 0.8 ng/mL. The patient’s pulse should be checked before administration, as always, and the digoxin should be administered. The digoxin does not have to be withheld, nor does the prescriber need to be notified. If the digoxin level is demonstrating a trend of increasing, the issue should be discussed in rounds. Digibind is not indicated, because the digoxin level is therapeutic.
A patient is in the intensive care unit after a myocardial infarction. The nurse notes that the QT interval on this patient’s electrocardiogram has been elongating. The nurse is concerned that which cardiac dysrhythmia may occur?
a. AV block
b. Bradycardia
c. Supraventricular tachycardia
d. Torsades de pointes
ANS: D
Torsades de pointes is a dysrhythmia that can occur with prolongation of the QT interval and can progress to fatal ventricular fibrillation. A prolonged QT interval does not signal the development of AV block, bradycardia, or SVT.
A patient in the emergency department has severe chest pain. The nurse administers morphine intravenously. The patient asks the nurse why morphine is given. Which response by the nurse is correct?
a. “Morphine helps by reducing anxiety and relieving pain.”
b. “Morphine helps by reducing pain and dissolving clots.”
c. “Morphine helps by relieving pain and lowering blood pressure.”
d. “Morphine helps by relieving pain and reducing the cardiac oxygen demand.”
ANS: D
IV morphine is the treatment of choice for STEMI-associated pain. Besides relieving pain, it promotes vasodilation and reduces cardiac preload, which lowers the cardiac oxygen demand. It does not reduce anxiety, dissolve clots, or lower blood pressure.
A patient diagnosed with hypertension has been prescribed antihypertensive medications along with lifestyle modifications. Which patient statement indicates correct understanding of pharmacologic and non-pharmacologic management of hypertension?
A. "As long as I exercise regularly, I can stop taking my medication."
B. "If I follow the DASH diet, I don’t need to restrict my sodium intake."
C. "I need to continue taking my medication even if I don’t feel any symptoms."
D. "Drinking alcohol won’t interfere with my blood pressure medications if I drink occasionally."
ANS: C
Hypertension is often asymptomatic ("the silent killer"), but medications must be taken consistently to control blood pressure and prevent organ damage, even if the patient feels well.
A patient with hypertension with a blood pressure of 168/110 mm Hg begins taking hydrochlorothiazide and verapamil. The patient returns to the clinic after 2 weeks of drug therapy, and the nurse notes a blood pressure of 140/85 mm Hg and a heart rate of 98 beats per minute. What will the nurse do?
a. Notify the provider and ask about adding a beta blocker medication.
b. Reassure the patient that the medications are working.
c. Remind the patient to move slowly from sitting to standing.
d. Request an order for an electrocardiogram.
ANS: A
Beta blockers are often added to drug regimens to treat reflex tachycardia, which is a common side effect of lowering blood pressure, caused by the baroreceptor reflex. The patient’s blood pressure is responding to the medications, but the tachycardia warrants treatment. Reminding the patient to move slowly from sitting to standing is appropriate with any blood pressure medication, but this patient has reflex tachycardia, which must be treated. An electrocardiogram is not indicated.
Which medications are included in first-line therapy for heart failure? (Select all that apply.)
a. Agents that inhibit the renin-angiotensin-aldosterone system (RAAS)
b. Aldosterone antagonists
c. Beta blockers
d. Cardiac glycosides
e. Diuretics
ANS: A, C, E
For routine therapy, heart failure is treated with agents that inhibit the RAAS, beta blockers, and diuretics. Aldosterone antagonists and cardiac glycosides are not first-line drugs for HF.
The nurse is teaching a class on dysrhythmias and associated therapy. The nurse asks the class, “Which cardiac dysrhythmia would result in the lowest cardiac output, and what treatment would be effective?” The class best demonstrates understanding by responding that
_____ results in the lowest cardiac output, and treatment includes _____.
a. atrial flutter; lidocaine
b. tachycardia; atropine
c. first-degree heart block; verapamil (Calan)
d. ventricular fibrillation; defibrillation
ANS: D
With ventricular fibrillation there is no cardiac output, because the pumping action of the heart stops. Treatment with electrical countershock is indicated to restore cardiac function. Atrial flutter, tachycardia, and first-degree heart block do not result in the lowest cardiac output.
A nurse is discussing the difference between stable and variant angina with a group of nursing students. Which statement by a student indicates the need for further teaching?
a. “Beta blockers are effective in stable angina but not in variant angina.”
b. “In both types of angina, prophylactic treatment is possible.”
c. “Variant angina is primarily treated with vasodilators to increase oxygen supply.”
d. “Variant angina is the result of increased oxygen demand by the heart.”
ANS: D
Variant angina is caused by coronary artery spasm, which reduces the oxygen supply to the heart. Beta blockers are not effective in variant angina but are useful with stable angina. Medications may be given to prevent anginal attacks in both types of angina. Vasodilators are used in variant angina to relieve coronary artery spasm and increase the oxygen supply to the heart.