HESI Case Study Coronary Artery Disease
Questions with complete Answer.
Knowing that the client has two risk factors that cannot be modified, which intervention
is most important for the nurse to include in the client's plan of care? - Answer Complete
a focused cardiac history assessment.
Myocardial infarction, coronary artery disease, and ischemic heart disease are among
the most common underlying causes of heart failure.
In fact, the most common cause of heart failure is myocardial infarction.
The nurse should also ask the client if they have hypertension which is another primary
underlying condition causing heart failure.
Clinical Manifestations
Right-sided, or right ventricular, heart failure - Answer Right-sided, or right ventricular,
heart failure occurs due to left-sided heart failure when the weakened or stiff left
ventricle cannot efficiently pump blood to the rest of the body. As a result, fluid is forced
back through the lungs, weakening the heart's right side, and causing right-sided heart
failure.
Which assessment finding provides the earliest indication that the client is experiencing
right-sided heart failure? - Answer Peripheral edema.
Right-sided heart failure results in peripheral congestion due to the inability of the right
ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an
enlarged liver, abdominal ascites, and weight gain.
Edema and weight gain are among the earlier signs.
Cardiac Dysrhythmias
Left-sided heart failure - Answer Left-sided heart failure results in pulmonary fluid
overload, and right-sided heart failure results in peripheral fluid overload.
Left-sided heart failure usually occurs first, and can trigger right-sided heart failure.
Based on the electrocardiogram rhythm strip, what intervention should the nurse
implement first?
Upon admission to the Cardiac Nursing Unit, the client's dyspnea continues. The client
reports fatigue but denies chest pain. The nurse places the client on oxygen via a nasal
cannula at 3 L/min and a cardiac telemetry monitor. The ECG recording shows no
discernible P waves and a rapid, irregular ventricular response (QRS complexes). This
corresponds with the client's pulse rate, which is 136 and irregular. - Answer Obtain a
12 lead ECG.
,A 12 lead should be performed immediately to confirm the rhythm and determine if there
is any acute myocardial injury occuring. Atrial fibrillation commonly occurs in heart
failure. Multiple areas in the atria initiate rapid, irregular electrical stimuli, which results
in the inability to see clear P waves on the ECG recording. Some, but not all, of these
electrical impulses travel through the AV node, causing an irregular ventricular
response. This appears as irregular QRS complexes on the ECG recording and
manifests as an irregular pulse rhythm when assessing the client.
Elective cardioversion. - Answer Cardioversion may be indicated to attempt to shock the
heart back into a regular rhythm but is not priority unless the patient is unstable.
After the client's cardiac rhythm is confirmed, which action should the nurse implement
next? - Answer Administer an ordered stat dose of digoxin.
If a dose of digoxin has already been prescribed, it should be administered before
taking further action.
Digoxin slows the heart rate and increases the force of the heart's contraction, which is
very useful in the treatment of the client's type of cardiac dysrhythmia.
When preparing the client for the echocardiogram, which intervention should the nurse
implement? - Answer Ask the client to lay supine during the test.
The echocardiogram records direction and flow of blood through the heart and
transforms it to audio and graphic data that measure valve abnormalities, congenital
heart defects, wall motion, ejection fraction (EF), and heart function.
The best results are obtained when the patient is in the supine position. The technician
may also request the client to lay on their left side.
The RN charge nurse prepares a dose of digoxin 0.125 mg IV push. The medication is
supplied as 0.25 mg in 2 mL. How many mL should the RN prepare to give? - Answer 1
ML
After administration of the prescribed captopril, which assessment finding warrants
intervention by the nurse? - Answer Decrease in baseline blood pressure.
Captopril is an angiotensin converting enzyme (ACE) inhibitor used as an
antihypertensive agent. ACE inhibitors have been shown to prolong survival in clients
with heart failure. By lowering the blood pressure (reduced afterload), the workload on
the heart is reduced. The nurse should monitor the client's blood pressure to ensure that
the medication is having the desired effect, and that hypotension does not occur.
Excessive hypotension and hyperkalemia may occur. Monitor the client for first-dose
hypotension (first-dose syncope).
, The nurse is monitoring the client's serum electrolytes. Which of the client's serum
laboratory values requires intervention by the nurse? - Answer Potassium 3.0 mEq/L
(3.0 mmol/L).
Normal potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The diuretic (furosemide)
decreases sodium reabsorption which enhances sodium and water loss putting the
client at risk for hypokalemia.
Even though 3.0 is not critically low, hypokalemia increases the risk for digoxin toxicity.
The client is concerned about how easily they are bruising since they started taking the
warfarin. Which intervention is most important for the nurse to include in the client's plan
of care? - Answer Monitor INR levels every 4-6 weeks.
The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis.
Changes in the warfarin dosage will be adjusted to keep the INR within a safe range
which will decrease the risk of a life-threatening bleed.
The nurse observed a family member bringing the client food from home. Which
intervention is most important for the nurse implement? - Answer Teach client and
family members what foods are low in sodium.
The client asks the nurse why they have to be weighed every day. The nurse explains
that weight gain is one of the first signs of retaining fluid. Which intervention is most
important for the nurse to include in the client's plan of care? - Answer Report a gain of
3 pounds in one week.
What is the first action that the nurse should implement when entering the client's room?
- Answer Elevate the head of the client's bed.
Since the nurse knows that the client is already experiencing impaired gas exchange
and is now obviously dyspneic, the first priority is to reduce the impaired gas exchange.
The nurse should first elevate the head of the bed and assist the client with deep
breathing to promote improved oxygenation. Oxygen saturation should be monitored via
pulse oximetry, and supplemental oxygen should be provided to maintain adequate
oxygenation. Additional assessment includes breath sounds, respiratory rate, rhythm,
and effort.
Select additional instruction(s) the nurse should include in the client's teaching plan. -
Answer Monitor pulse prior to administration of digoxin.
It is necessary to monitor pulse while receiving digoxin.
Do not stop taking any prescribed potassium supplements.
Questions with complete Answer.
Knowing that the client has two risk factors that cannot be modified, which intervention
is most important for the nurse to include in the client's plan of care? - Answer Complete
a focused cardiac history assessment.
Myocardial infarction, coronary artery disease, and ischemic heart disease are among
the most common underlying causes of heart failure.
In fact, the most common cause of heart failure is myocardial infarction.
The nurse should also ask the client if they have hypertension which is another primary
underlying condition causing heart failure.
Clinical Manifestations
Right-sided, or right ventricular, heart failure - Answer Right-sided, or right ventricular,
heart failure occurs due to left-sided heart failure when the weakened or stiff left
ventricle cannot efficiently pump blood to the rest of the body. As a result, fluid is forced
back through the lungs, weakening the heart's right side, and causing right-sided heart
failure.
Which assessment finding provides the earliest indication that the client is experiencing
right-sided heart failure? - Answer Peripheral edema.
Right-sided heart failure results in peripheral congestion due to the inability of the right
ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an
enlarged liver, abdominal ascites, and weight gain.
Edema and weight gain are among the earlier signs.
Cardiac Dysrhythmias
Left-sided heart failure - Answer Left-sided heart failure results in pulmonary fluid
overload, and right-sided heart failure results in peripheral fluid overload.
Left-sided heart failure usually occurs first, and can trigger right-sided heart failure.
Based on the electrocardiogram rhythm strip, what intervention should the nurse
implement first?
Upon admission to the Cardiac Nursing Unit, the client's dyspnea continues. The client
reports fatigue but denies chest pain. The nurse places the client on oxygen via a nasal
cannula at 3 L/min and a cardiac telemetry monitor. The ECG recording shows no
discernible P waves and a rapid, irregular ventricular response (QRS complexes). This
corresponds with the client's pulse rate, which is 136 and irregular. - Answer Obtain a
12 lead ECG.
,A 12 lead should be performed immediately to confirm the rhythm and determine if there
is any acute myocardial injury occuring. Atrial fibrillation commonly occurs in heart
failure. Multiple areas in the atria initiate rapid, irregular electrical stimuli, which results
in the inability to see clear P waves on the ECG recording. Some, but not all, of these
electrical impulses travel through the AV node, causing an irregular ventricular
response. This appears as irregular QRS complexes on the ECG recording and
manifests as an irregular pulse rhythm when assessing the client.
Elective cardioversion. - Answer Cardioversion may be indicated to attempt to shock the
heart back into a regular rhythm but is not priority unless the patient is unstable.
After the client's cardiac rhythm is confirmed, which action should the nurse implement
next? - Answer Administer an ordered stat dose of digoxin.
If a dose of digoxin has already been prescribed, it should be administered before
taking further action.
Digoxin slows the heart rate and increases the force of the heart's contraction, which is
very useful in the treatment of the client's type of cardiac dysrhythmia.
When preparing the client for the echocardiogram, which intervention should the nurse
implement? - Answer Ask the client to lay supine during the test.
The echocardiogram records direction and flow of blood through the heart and
transforms it to audio and graphic data that measure valve abnormalities, congenital
heart defects, wall motion, ejection fraction (EF), and heart function.
The best results are obtained when the patient is in the supine position. The technician
may also request the client to lay on their left side.
The RN charge nurse prepares a dose of digoxin 0.125 mg IV push. The medication is
supplied as 0.25 mg in 2 mL. How many mL should the RN prepare to give? - Answer 1
ML
After administration of the prescribed captopril, which assessment finding warrants
intervention by the nurse? - Answer Decrease in baseline blood pressure.
Captopril is an angiotensin converting enzyme (ACE) inhibitor used as an
antihypertensive agent. ACE inhibitors have been shown to prolong survival in clients
with heart failure. By lowering the blood pressure (reduced afterload), the workload on
the heart is reduced. The nurse should monitor the client's blood pressure to ensure that
the medication is having the desired effect, and that hypotension does not occur.
Excessive hypotension and hyperkalemia may occur. Monitor the client for first-dose
hypotension (first-dose syncope).
, The nurse is monitoring the client's serum electrolytes. Which of the client's serum
laboratory values requires intervention by the nurse? - Answer Potassium 3.0 mEq/L
(3.0 mmol/L).
Normal potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The diuretic (furosemide)
decreases sodium reabsorption which enhances sodium and water loss putting the
client at risk for hypokalemia.
Even though 3.0 is not critically low, hypokalemia increases the risk for digoxin toxicity.
The client is concerned about how easily they are bruising since they started taking the
warfarin. Which intervention is most important for the nurse to include in the client's plan
of care? - Answer Monitor INR levels every 4-6 weeks.
The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis.
Changes in the warfarin dosage will be adjusted to keep the INR within a safe range
which will decrease the risk of a life-threatening bleed.
The nurse observed a family member bringing the client food from home. Which
intervention is most important for the nurse implement? - Answer Teach client and
family members what foods are low in sodium.
The client asks the nurse why they have to be weighed every day. The nurse explains
that weight gain is one of the first signs of retaining fluid. Which intervention is most
important for the nurse to include in the client's plan of care? - Answer Report a gain of
3 pounds in one week.
What is the first action that the nurse should implement when entering the client's room?
- Answer Elevate the head of the client's bed.
Since the nurse knows that the client is already experiencing impaired gas exchange
and is now obviously dyspneic, the first priority is to reduce the impaired gas exchange.
The nurse should first elevate the head of the bed and assist the client with deep
breathing to promote improved oxygenation. Oxygen saturation should be monitored via
pulse oximetry, and supplemental oxygen should be provided to maintain adequate
oxygenation. Additional assessment includes breath sounds, respiratory rate, rhythm,
and effort.
Select additional instruction(s) the nurse should include in the client's teaching plan. -
Answer Monitor pulse prior to administration of digoxin.
It is necessary to monitor pulse while receiving digoxin.
Do not stop taking any prescribed potassium supplements.
