Correct answer—B. Rationales: Sodium bicarbonate shouldn’t be given by way of an ET tube because of its alkalinity and because the large amounts required shouldn’t be administered by this route. Atropine, epinephrine, and lidocaine are absorbed rapidly by the lungs and may be given safely by way of an ET tube.

Nursing process step: Intervention

Correct answer—B. Rationales: A client with heart failure has reduced cardiac output because of the heart’s decreased pumping ability. Therefore, fluid builds up and causes dyspnea, edema, hepatomegaly, crackles, and distended jugular veins. A client with pulmonary embolism has acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade has muffled heart sounds, hypotension, and elevated venous pressure. A client with tension pneumothorax has a deviated trachea and no breath sounds on the affected side as well as dyspnea and distended jugular veins.

Nursing process step: Assessment

Correct answer—D. Rationales: The client’s pain is caused by myocardial ischemia. Oxygen increases the myocardial oxygen supply. Cardiac monitoring reveals life-threatening arrhythmias. The nurse should ensure that the client isn’t hypotensive before giving sublingual nitroglycerin for chest pain. Registration may be delayed until the client is stabilized. Alerting the catheter laboratory team before completing an initial assessment is premature.

Nursing process step: Intervention

Correct answer—C. Rationales: The client is experiencing premature ventricular contractions (PVCs). Lidocaine is the drug of choice for PVCs associated with chest pain and a normal heart rate. Magnesium sulfate is used in torsades de pointes. Amiodarone is used only for life-threatening ventricular arrhythmias. Atropine is used to increase heart rate, which is not necessary in this situation.

Nursing process step: Intervention

Correct answer—B. Rationales: First determine the concentration:

Then determine the drip rate:

Nursing process step: Intervention

Correct answer—A. Rationales: Active bleeding is an absolute contraindication for thrombolytic therapy. The other options are considered relative risks and should be evaluated before administering thrombolytics.

Nursing process step: Assessment

Correct answer—A. Rationales: Bleeding is a complication of thrombolytic therapy. Bradycardia—not tachycardia—is a common reperfusion arrhythmia (others are accelerated idioventricular and ventricular ectopy). The client should also have less chest pain. Headache isn’t associated with thrombolytic therapy.

Nursing process step: Assessment

Correct answer—C. Rationales: Diuretics decrease preload by eliminating sodium and water from the body and decrease dyspnea, increase urine output, and decrease JVD.

Nursing process step: Evaluation

Correct answer—A. Rationales: Therapy goals for a client with acute heart failure are to reduce myocardial workload in order to increase cardiac output; decrease volume, which causes dyspnea and edema; and increase myocardial contractility to increase cardiac output. Heart failure is a low cardiac output state.

Nursing process step: Evaluation

Correct answer—B. Rationales: Based on the assessment findings of both hypotension and muffled heart sounds, the client is experiencing cardiac tamponade. Immediate intervention by way of pericardiocentesis is necessary to correct the problem in order to prevent the client from experiencing cardiac arrest. CT of the chest will confirm fluid accumulation around the pericardium but will delay treatment. Insertion of the central venous catheter may be needed for fluid replacement in the absence of I.V. access. Insertion of a chest tube isn’t necessary at this time because the client has equal breath sounds bilaterally.

Nursing process step: Analysis

Correct answer—C. Rationales: The client presents with a blood pressure of 210/130 mm Hg, blurred vision, headaches, and chest pain, which are all consistent findings of a client experiencing a hypertensive crisis. The findings listed here aren’t consistent with acute MI, heart failure, or pericarditis.

Nursing process step: Analysis

Correct answer—C. Rationales: Labetalol administration can cause hypotension, bradycardia, and heart blocks, so monitoring of both the blood pressure and the heart rate and rhythm is essential for safe administration. It isn’t necessary to dilute the medication and hang as a piggyback. Labetalol can be administered I.V. push over 2 minutes—not 10 seconds. Labetalol doesn’t need to be divided into 4 equal doses for administration.

Nursing process step: Intervention

Correct answer—A. Rationales: A client with a ruptured aorta requires immediate surgery. Chest tubes shouldn’t be inserted. Diagnosis can be made with chest X-ray. A CT scan would delay definitive treatment. Intubation is done at the time of surgery, unless otherwise indicated.

Nursing process step: Intervention

Correct answer—C. Rationales: The client’s ECG strip shows bradycardia, and atropine is the drug of choice for treating symptomatic bradycardia. The 2010 American Heart Association guidelines recommend repeating the 0.5-mg dose at 3- to 5-minute intervals until 3 mg has been given. Pacing may be indicated if atropine is ineffective. Dopamine isn’t a first-line drug for treating bradycardia. However, it’s used to treat hypotension. In this case, bradycardia is the cause of hypotension and should be addressed first. Lidocaine shouldn’t be given for bradycardia because it may suppress the escape rhythm and lead to further hypotension and, possibly, asystole.

Nursing process step: Intervention

Correct answer—C. Rationales: Immediately defibrillate at 200 joules according to advanced cardiac life support protocol. A precordial thump isn’t part of the 2010 American Heart Association guidelines. Lidocaine can be administered as an alternative to amiodarone for persistent pulseless ventricular tachycardia if defibrillation and epinephrine are ineffective. Adenosine isn’t effective for ventricular tachycardias.

Nursing process step: Intervention

Correct answer—D. Rationales: Seizures are a symptom of lidocaine toxicity. Hypertension, tachycardia, and increased intracranial pressure aren’t commonly associated with lidocaine toxicity.

Nursing process step: Evaluation

Correct answer—C. Rationales: Thrombolytic therapy effectiveness is measured by the relief of chest pain, presence of reperfusion arrhythmias, and normalization of the ST segment. Oozing of blood from I.V. sites may occur because thrombolytic therapy may increase bleeding time, but bleeding doesn’t demonstrate its effectiveness.

Nursing process step: Assessment

Correct answer—B. Rationales: Increased temperature increases oxygen demands on the extremity. Maintaining the extremity in a dependent position promotes blood flow. Using Doppler ultrasound aids in assessing for worsening of the occlusion. The client may need surgery.

Nursing process step: Intervention

Correct answer—C. Rationales: Muffled heart sounds are associated with cardiac tamponade. A volume-depleted client with cardiac tamponade may not respond to volume infusion. Myocardial contusion presents with chest pain and electrocardiogram changes. Tension pneumothorax presents with acute increases in respiratory rate and heart rate, chest pain, tracheal deviation to the unaffected side, and an absence of breath sounds on the affected side. Aortic injury presents with a widened mediastinum by chest X-ray, hypotension, respiratory distress, and chest pain.

Nursing process step: Assessment

Correct answer—A. Rationales: Deceleration may cause laceration to the aorta by shearing forces. The other options may cause aortic injuries but aren’t the primary mechanisms of injury.

Nursing process step: Assessment

Correct answer—D. Rationales: If the needle touches the myocardium, PVCs or ST-segment elevation may be observed. The needle hasn’t necessarily entered the heart. At this time, the needle should be withdrawn slightly. The physician should aspirate the syringe while advancing the needle and should stop as soon as blood is obtained.

Nursing process step: Intervention

Correct answer—C. Rationales: Systemic lupus erythematosus as well as chest trauma and pericarditis may cause an accumulation of fluid in the pericardial sac, leading to cardiac tamponade. The other options don’t result in cardiac tamponade.

Nursing process step: Evaluation

Correct answer—A. Rationales: A client with a ruptured descending aorta may have a greater pulse amplitude in the arms than in the legs because of decreased perfusion to the legs. Blood pressure differences in arms are indicative of ruptured subclavian arteries. Distended jugular veins and muffled heart sounds aren’t likely to be present in this client.

Nursing process step: Assessment

Correct answer—B. Rationales: Anterior wall injury is associated with ECG changes in leads V1, V2, and V3. Inferior wall injury is associated with ECG changes in leads II, III, and aVF. Lateral wall injury is associated with ECG changes in leads I, aVL, V5, and V6. Posterior wall injury is associated with ECG changes in leads V1 and V2.

Nursing process step: Assessment

Correct answer—B. Rationales: The pain of acute MI won’t be relieved by the administration of nitroglycerin. This differentiates it from anginal pain, which should respond to nitroglycerin administration and oxygen. Heart failure isn’t commonly associated with substernal chest pain, and pericarditis isn’t common in a hypertensive client with CAD.

Nursing process step: Assessment

Correct answer—A. Rationales: Hypothermia, hypovolemia, and electrolyte imbalances can potentially cause ventricular fibrillation and may need to be treated before standard measures are effective. Digoxin toxicity can cause atrial tachycardia—not ventricular fibrillation.

Nursing process step: Evaluation