Management of Patients with Coronary
Vascular Disorders NCLEX questions
and correct answers 100% correct
d
(Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer
supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect
life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving
sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is
stabilized. Alerting the cardiac catheterization team or the physician before completing the initial
assessment is premature.) - correct answer ✔✔A client in the emergency department complains of
squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea,
diaphoresis, and shortness of breath. What should the nurse do?
a) Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and
take vital signs.
b) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the
physician.
c) Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team.
d) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
c
(Acute pain
The nursing diagnosis of Acute pain takes highest priority because it increases the client's pulse and
blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's
response to myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect
,answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac
output. Anxiety could be an appropriate nursing diagnosis, but addressing Acute pain (the priority
concern) may alleviate the client's anxiety.) - correct answer ✔✔Shortly after being admitted to the
coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain
radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and
measures a temperature of 99.6° F (37.6° C); a heart rate of 102 beats/minute; regular, slightly labored
respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis
takes highest priority?
a) Decreased cardiac output
b) Risk for imbalanced body temperature
c) Acute pain
d) Anxiety
d
(Atropine
Removing the sheath after cardiac catheterization may cause a vasovagal response, including
bradycardia. The nurse should have atropine on hand to increase the client's heart rate if this occurs.
Heparin thins the blood; clients should stop taking it before the sheath removal. Protamine sulfate is an
antidote to heparin, but the nurse shouldn't administer it during sheath removal. Adenosine treats
tachyarrhythmias.) - correct answer ✔✔Which medication should a nurse have on hand when removing
a sheath after cardiac catheterization?
a) Heparin
b) Adenosine (Adenocard)
c) Protamine sulfate
d) Atropine
c
(myocardial necrosis.
, An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several
reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from
I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.) -
correct answer ✔✔Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of:
a) skeletal muscle damage due to a recent fall.
b) I.M. injection.
c) myocardial necrosis.
d) cerebral bleeding.
c
(Nitroglycerin SL
Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be
renewed every 6 months to ensure full potency. The client's tablets were expired and the nurse should
anticipate administering nitroglycerin to assess if the chest pain subsides. The other choices may be
ordered at a later time, but the priority is to relieve the patient's chest pain.) - correct answer ✔✔A
patient presents to the ED complaining of anxiety and chest pain after shoveling heavy snow that
morning. The patient says that he has not taken nitroglycerin for months but did take three nitroglycerin
tablets and although the pain is less, "They did not work all that well. " The patient shows the nurse the
nitroglycerin bottle and the prescription was filled 12 months ago. The nurse anticipates which of the
following physician orders?
a) Serum electrolytes
b) Ativan 1 mg orally
c) Nitroglycerin SL
d) Chest x-ray
a
(Worsening angina
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