(ANSWERS and RATIONALE) – Coronary Artery Disease and Hypertension NCLEX Review

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1. ANSWER D. This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.

2. ANSWER C. Chest pain is assessed by using the standard pain assessment parameters. Options A, B, and D may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

3. ANSWER B. On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances are encouraged, with distances gradually increased (50, 100, 200 feet).

4. ANSWER A. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

5. ANSWER A. Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.

6. ANSWER D. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy.

7. ANSWER D. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin.

8. ANSWER C. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range.

9. ANSWER B. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

10. ANSWER A. Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse’s priority action would be to relieve the crushing chest pain.

11. ANSWER B. Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage.

12. ANSWERS A, C, E. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

13. ANSWER B. Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood are important but secondary to starting the intravenous line.

14. ANSWER D. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is normal).

15. ANSWER A. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.

16. ANSWER C. Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance.

17. ANSWER A. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVA’s can be related to long-term hypertension. Liver or pulmonary disease is generally not associated with hypertension. Myocardial infarction is generally related to coronary artery disease.

18. ANSWER C. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

19. ANSWER A. The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD.

20. ANSWER B. Cardiac catherization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catherization results.