Case 1 Chest Pressure, Indigestion, Nausea, and Vomiting Ms. S

Case 1 Chest Pressure, Indigestion, Nausea, and Vomiting Ms. S is a 58-year-old African-American woman who was admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea. She started feeling ill about 10 hours before she called her daughter, who brought her to the ED for admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate that was in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She states, “It just gets worse and worse.” Ms. S has been under a health care provider ‘s (HCP ‘s) care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker for 43 years but quit 1 year ago. Her past medical history includes gall bladder disease and gastroesophageal reflux disease (GERD). In the ED, admission laboratory tests, including levels of cardiac markers, were performed, and a 12- lead electrocardiogram (ECG) was taken. Ms. S ‘s CCU vital sign values on admission are as follows: Blood pressure 174/92 mm Hg Heart rate 120 to 130 beats/min, irregular O2 saturation 91% on room air Respiratory rate 30 to 34 breaths/min Temperature 99.8° F (37.7° C) (oral) 1.Based on Ms. S’s admission vital signs, which HCP orders would the nurse expect? Select all that apply. Your Answers: 1 Continuous cardiac monitoring 2 Blood pressure checks every 10 minutes 3 Oxygen at 2 L per nasal canula 4 Instruct patient to breathe and rebreathe into a paper bag. 5 Acetaminophen 650 mg as needed for temperature greater than 99°F (37.2°C) 6 Check apical heart rate with each set of vital signs 2. Which risk factors from Ms. S’s history would suggest a possible cardiac problem to the nurse? Select all that apply. 1 Hypertension for 12 years 2 Smoked for 43 years; quit smoking 1 year ago 3 Surgery for gallbladder removal 1 year ago 4 Ms. S’s father died at age 42 years from a heart attack 5 Patient’s weight is 278 lb (126 kg) 6 Diet includes fast foods three to five times a week 7 Patient is an African-American female 8 History of gastroesophageal reflux disease 9 Report of chest pressure and indigestion associated with nausea 3. Which action is best for the nurse to delegate to a new assistive personnel (AP) orienting to the CCU when caring for Ms. S? 1 Placing the patient on a cardiac telemetry monitor 2 Drawing blood to test cardiac marker levels and sending it to the laboratory 3 Obtaining a 12-lead ECG 4 Checking and recording the patient’s intake and output 4. Which action prescribed by the health care provider (HCP) for Ms. S takes first priority at this time? 1 Measure vital signs every 2 hours. 2 Obtain a 12-lead ECG every 6 hours. 3 Place the patient on a cardiac monitor. 4 Check levels of cardiac markers every 6 hours. 5.Ms. S’s cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs) and short runs of ventricular tachycardia (more than 3 PVCs in a row). Which drug should the nurse be prepared to administer first? 1 Amiodarone IV push 2 Nitroglycerin sublingually 3 Morphine sulfate IV push 4 Atenolol IV push 6. All of these laboratory values were obtained for Ms. S in the emergency department. Which value would be of most concern to the nurse and have immediate implications for the care of the patient? 1 Potassium level of 3.5 mEq/L (3.5 mmol/L) 2 Troponin T level of more than 0.20 ng/mL (0.2 μg/L) 3 Glucose level of 123 mg/dL (6.83 mmol/L) 4 Slight elevation of white blood cell count. 7. Ms. S tells the nurse that she has worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and the nurse notifies the HCP. Which prescribed action takes the highest priority at this time? 1 Administer morphine sulfate 2 mg IV push. 2 Schedule an ECG. 3 Draw blood for coagulation studies. 4 Administer ranitidine 75 mg PO every 12 hours. 8. Because Ms. S continues to experience chest discomfort and has elevated levels of cardiac markers, the following interventions have been prescribed by the health care provider. Which interventions should the nurse delegate to an experienced AP? Select all that apply. 1 Measuring vital signs every 2 hours 2 Accurately recording intake and output 3 Administering tenecteplase IV push 4 Drawing blood for coagulation studies 5 Assessing the cardiac monitor every 4 hours 6 Assisting the patient to the bedside commode 7 Helping the patient with morning care and partial bed bath 8 Assessing the patient’s pain level 9. The patient is scheduled for an emergent cardiac catheterization with possible percutaneous coronary intervention (PCI). Ms. S asks the nurse what is involved with this procedure. What is the nurse’s best response? 1 “It is a procedure that is usually done on patients who have heart attacks to diagnose blockages in the arteries that feed the heart.” 2 “The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open.” 3 “Cardiac catheterization is usually performed on an outpatient basis to determine whether or not you have had a heart attack.” 4 “After the cardiac catheterization, you will come back to the coronary care unit, where you will be on bed rest for 6 to 8 hours, and we will check your vital signs often.” 10 Ms. S has returned to the CCU after a cardiac catheterization and a percutaneous coronary intervention procedure. Which follow-up care orders should the nurse assign to an experienced LPN/LVN? Select all that apply. 1 Reminding the patient to remain on bed rest with the insertion site extremity straight 2 Preparing a teaching plan that includes activity restrictions and risk factor modification 3 Measuring the patient’s vital signs every 15 minutes for the first hour 4 Assessing the catheter insertion site for bleeding or hematoma formation 5 Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs 6 Administering two tablets of acetaminophen for back pain 11. Which information is most important to prevent recurrence of re-occlusion of the coronary artery, chest discomfort, or myocardial infarction? 1 Remain on bed rest for the next 24 hours. 2 Patient will be prescribed dual antiplatelet therapy (DAT). 3 Patient should do no heavy lifting for 48 hours. 4 HCP will prescribe a beta-blocker. 12. Ms. S’s daughter asks the nurse why her mother did not receive a “clot-buster” drug. What is the nurse’s best response? 1 “Thrombolytic agents, also called clot busters, are most effective when administered within the first 6 hours of a coronary event.” 2 drugs are much more effective when used for patients who have had a recent stroke.” 3 “Thrombolytic drugs work better for patients who have a heart attack at a much younger age.” 4 “Contraindications for these drugs include recent surgeries, and your mother had gallbladder surgery a year ago.” 13. Ms. S’s condition is stable, and she has been transferred to the cardiac step-down unit. What should the step-down nurse instruct the AP to report immediately? 1 Temperature of 99°F (37.2°C) with morning vital sign monitoring 2 Chest pain episode occurring during morning care 3 Systolic blood pressure increase of 8 mm Hg after morning care 4 Heart rate increase of 10 beats/min after ambulation 14. The nurse delegates to the AP the task of taking Ms. S’s vital signs every 4 hours and recording the vital sign values in the electronic chart. Later the nurse checks the patient’s chart and discovers that vital sign measurements have not been recorded. What is the nurse’s best action? 1 Take the vital signs because the AP is not competent to complete this task. 2 Notify the nurse manager immediately. 3 Reprimand the AP at the nurses’ station. 4 Speak to the AP privately to determine why the values were not recorded. 15. The HCP prescribes captopril 12.5 mg orally twice daily and hydrochlorothiazide (HCTZ) 25 mg orally daily. Which information would the nurse be sure to include when teaching Ms. S about these drugs? 1 “Take your HCTZ in the morning.” 2 “If you miss a dose of captopril, take two tablets next time.” 3 “Avoid foods that are rich in potassium, such as bananas and oranges.” 4 “You should expect an increase in blood pressure with these drugs.” 16. The HCP orders dual antiplatelet therapy (DAT) for Ms. S. What is the nurse’s highest priority concern for this patient? 1 Reminding the patient to do no heavy lifting while hospitalized 2 Assessing the progression of walking in the halls 3 Teaching the patient to apply oxygen for any shortness of breath 4 Monitoring the patient for any form of bleeding 17. The HCP prescribes atenolol 50 mg each morning for Ms. S. Which instruction would the nurse provide for the LPN/LVN assigned to give this drug? 1 Hold the drug if the patient’s blood pressure is higher than 100/80 mm Hg. 2 Give the drug if the patient’s respiratory rate is greater than 30 breaths/min. 3 Hold the drug if the patient’s heart rate is less than 55 beats/min. 4 Give the drug if the patient’s blood pressure is less than 90/50 mm Hg. 18. Which activities could the nurse delegate to AP assisting Ms. S during phase 1 of cardiac rehabilitation? Select all that apply. 1 Assist with Ms. S’s morning bath as needed. 2 Refer Ms. S to a monitored cardiac rehab program. 3 Ambulate with Ms. S to the bathroom. 4 Administer Ms. S’s morning doses of captopril and HCTZ. 5 Assist with progressive ambulation in the hall. 6 Assess Ms. S for additional chest pain or pressure. 19. Before discharging Ms. S, the HCP orders an electrocardiogram (ECG). This test reveals normal sinus rhythm with a heart rate of 87 beats/min (see the figure). What is the nurse’s best action at this time? 1 Delay the patient’s discharge until she is seen by the HCP. 2 Administer the patient’s next dose of atenolol 3 hours early before she goes home. 3 Contact the HCP and ask about drawing an additional set of cardiac markers. 4 Document this finding as the only action and prepare for discharge.

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