ACS/MI EXAM 2 COMPLETE
QUESTIONS AND 100% CORRECT
ANSWERS
\.2. The nurse is preparing to administer nitroglycerin, a coronary vasodilator
transdermal patch, to the client diagnosed with a myocardial infarction. Which
intervention should the nurse implement?
Question applying the patch if the client's BP is less than 110/70.
Use nonsterile gloves when applying the transdermal patch.
Date and time the transdermal patch prior to applying to client's skin.
Place the transdermal patch on the site where the old patch was removed. -
ANSWERS✔-Date and time the transdermal patch prior to applying to client's skin.
The nurse should remove the old patch, wash the client's skin, note the date and
time the new patch is applied, and apply it in a new area that is not hairy.
\.3. The client is complaining of severe chest pain radiating down the left arm and
is nauseated and diaphoretic. The HCP suspects the client is having a myocardial
infarction (MI) and has ordered morphine sulfate (MS), a narcotic analgesic, for
the pain. Which interventions should the nurse implement? Select all that apply.
Instruct the client not to get up out of the bed without notifying the nurse.
,Administer the morphine sulfate (MS) intramuscularly in the ventral gluteal
muscle.
Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline.
Administer the morphine sulfate (MS) slowly over 5 minutes.
Question the order because morphine sulfate (MS) should not be administered to
a client with a myocardial infarction (MI). - ANSWERS✔-Instruct the client not to
get up out of the bed without notifying the nurse.
Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline.
Administer the morphine sulfate (MS) slowly over 5 minutes.
The client should not get out of the bed without assistance due to the drowsiness
the client will experience after receiving MS. Also, the client is having chest pain
and should not get out of the bed without assistance
Morphine sulfate is the drug of choice for chest pain, and it is administered
intravenously so that it acts as soon as possible, within 10-15 minutes.
Intravenous push medications should be diluted to help decrease the pain when it
is administered and to prevent irritation to the vein.
An intravenous push also allows the nurse to inject the medication more
accurately over the 5-minute administration time.
\.The nurse is administering 0900 medications to the following clients. Which
client should the nurse question administering the medication?
,The client receiving a calcium channel blocker who drank a glass of grapefruit
juice.
The client receiving a beta blocker who has an apical pulse of 62 beats per minute.
The client receiving a nitroglycerin patch who has a blood pressure of 148/92.
The client receiving an antiplatelet medication who has a platelet count of
150,000. - ANSWERS✔-The client receiving a calcium channel blocker (CCB) should
avoid grapefruit juice because it can cause the CCB to rise to toxic levels.
\.6. The client diagnosed with a myocardial infarction is receiving thrombolytic
therapy. Which data warrants immediate intervention by the nurse?
The client's telemetry has reperfusion dysrhythmias.
The client is oozing blood from the intravenous site.
The client is alert and oriented to date, time, and place.
The client has no signs of infiltration at the insertion site. - ANSWERS✔-Any
bleeding from the intravenous site, gums, rectum, or vagina should be reported to
the HCP. The HCP may not be able to take intervention to prevent the bleeding
during therapy, but it warrants notifying the HCP.
\.8. The client being discharged after sustaining an acute myocardial infarction is
prescribed the ACE inhibitor lisinopril (Zestril). Which instruction should the nurse
include when teaching about this medication?
Instruct the client to monitor the blood pressure weekly.
Encourage the client to take medication on an empty stomach.
, Discuss the need to rise slowly from lying to a standing position.
Teach the client to take the medication at night only. - ANSWERS✔-This
medication causes orthostatic hypotension, and the client should be instructed to
rise slowly from lying to sitting to standing position to prevent falls and injury.
\.9. The client calls the clinic and says, "I am having chest pain. I think I am having
another heart attack." Which intervention should the nurse implement first?
Call 911 emergency medical services.
Instruct the client to take an aspirin.
Determine if the client is at home alone.
Ask if the client has any sublingual nitroglycerin. - ANSWERS✔-Because the client
has had one myocardial infarction, the client may have sublingual nitroglycerin in
a pocket and can take it immediately. If the client does not have any on the body,
then the nurse should determine if there is anyone in the home that can help the
client.
\.The nurse is caring for an adult patient who had symptoms of unstable angina
upon admission to the
hospital. What nursing diagnosis underlies the discomfort associated with angina?
A) Ineffective breathing pattern related to decreased cardiac output
B) Anxiety related to fear of death
C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease
(CAD)
D) Impaired skin integrity related to CAD - ANSWERS✔-Ans: C
QUESTIONS AND 100% CORRECT
ANSWERS
\.2. The nurse is preparing to administer nitroglycerin, a coronary vasodilator
transdermal patch, to the client diagnosed with a myocardial infarction. Which
intervention should the nurse implement?
Question applying the patch if the client's BP is less than 110/70.
Use nonsterile gloves when applying the transdermal patch.
Date and time the transdermal patch prior to applying to client's skin.
Place the transdermal patch on the site where the old patch was removed. -
ANSWERS✔-Date and time the transdermal patch prior to applying to client's skin.
The nurse should remove the old patch, wash the client's skin, note the date and
time the new patch is applied, and apply it in a new area that is not hairy.
\.3. The client is complaining of severe chest pain radiating down the left arm and
is nauseated and diaphoretic. The HCP suspects the client is having a myocardial
infarction (MI) and has ordered morphine sulfate (MS), a narcotic analgesic, for
the pain. Which interventions should the nurse implement? Select all that apply.
Instruct the client not to get up out of the bed without notifying the nurse.
,Administer the morphine sulfate (MS) intramuscularly in the ventral gluteal
muscle.
Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline.
Administer the morphine sulfate (MS) slowly over 5 minutes.
Question the order because morphine sulfate (MS) should not be administered to
a client with a myocardial infarction (MI). - ANSWERS✔-Instruct the client not to
get up out of the bed without notifying the nurse.
Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline.
Administer the morphine sulfate (MS) slowly over 5 minutes.
The client should not get out of the bed without assistance due to the drowsiness
the client will experience after receiving MS. Also, the client is having chest pain
and should not get out of the bed without assistance
Morphine sulfate is the drug of choice for chest pain, and it is administered
intravenously so that it acts as soon as possible, within 10-15 minutes.
Intravenous push medications should be diluted to help decrease the pain when it
is administered and to prevent irritation to the vein.
An intravenous push also allows the nurse to inject the medication more
accurately over the 5-minute administration time.
\.The nurse is administering 0900 medications to the following clients. Which
client should the nurse question administering the medication?
,The client receiving a calcium channel blocker who drank a glass of grapefruit
juice.
The client receiving a beta blocker who has an apical pulse of 62 beats per minute.
The client receiving a nitroglycerin patch who has a blood pressure of 148/92.
The client receiving an antiplatelet medication who has a platelet count of
150,000. - ANSWERS✔-The client receiving a calcium channel blocker (CCB) should
avoid grapefruit juice because it can cause the CCB to rise to toxic levels.
\.6. The client diagnosed with a myocardial infarction is receiving thrombolytic
therapy. Which data warrants immediate intervention by the nurse?
The client's telemetry has reperfusion dysrhythmias.
The client is oozing blood from the intravenous site.
The client is alert and oriented to date, time, and place.
The client has no signs of infiltration at the insertion site. - ANSWERS✔-Any
bleeding from the intravenous site, gums, rectum, or vagina should be reported to
the HCP. The HCP may not be able to take intervention to prevent the bleeding
during therapy, but it warrants notifying the HCP.
\.8. The client being discharged after sustaining an acute myocardial infarction is
prescribed the ACE inhibitor lisinopril (Zestril). Which instruction should the nurse
include when teaching about this medication?
Instruct the client to monitor the blood pressure weekly.
Encourage the client to take medication on an empty stomach.
, Discuss the need to rise slowly from lying to a standing position.
Teach the client to take the medication at night only. - ANSWERS✔-This
medication causes orthostatic hypotension, and the client should be instructed to
rise slowly from lying to sitting to standing position to prevent falls and injury.
\.9. The client calls the clinic and says, "I am having chest pain. I think I am having
another heart attack." Which intervention should the nurse implement first?
Call 911 emergency medical services.
Instruct the client to take an aspirin.
Determine if the client is at home alone.
Ask if the client has any sublingual nitroglycerin. - ANSWERS✔-Because the client
has had one myocardial infarction, the client may have sublingual nitroglycerin in
a pocket and can take it immediately. If the client does not have any on the body,
then the nurse should determine if there is anyone in the home that can help the
client.
\.The nurse is caring for an adult patient who had symptoms of unstable angina
upon admission to the
hospital. What nursing diagnosis underlies the discomfort associated with angina?
A) Ineffective breathing pattern related to decreased cardiac output
B) Anxiety related to fear of death
C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease
(CAD)
D) Impaired skin integrity related to CAD - ANSWERS✔-Ans: C
