Cardiac practice questions

Question 1

The nurse is reviewing a newly signed Physician Orders for Life-Sustaining Treatment (POLST) form with a client who has advanced heart failure and is being discharged tomorrow. Which statement by the client shows correct understanding of the form?

Accepted Answer

D: "My POLST is a medical order that I should keep where paramedics can find it.". A Physician Orders for Life-Sustaining Treatment (POLST) form is a portable medical order signed by the client (or the client's surrogate) and a provider. It travels with the client and is followed by emergency medical services, hospitals and long-term care facilities in states with a POLST program. Names vary by state (MOLST, MOST, POST). It is meant for people with serious illness or frailty and is kept where emergency responders can see it. It can be reviewed and changed when the client's condition or wishes change, and it does not replace an advance directive or a health care agent.

Question 2

The charge nurse on a cardiac step-down unit will divide four clients for the day shift between a registered nurse (RN) and a licensed practical nurse (LPN). Which client should be assigned to the LPN?

Accepted Answer

C: Client 2 days after a percutaneous coronary intervention (PCI) with stable vital signs and scheduled oral medications. The LPN cares for clients who are stable and whose outcomes are predictable, and gives routine medications. A client 2 days after a percutaneous coronary intervention with stable vital signs who needs scheduled oral medications fits that description exactly.

The RN keeps the clients who need assessment, titration, judgment about a changing condition, and monitoring during a high-risk period. That covers the other three clients.

Question 3

At 1400 a 61-year-old client admitted with pneumonia reports substernal chest pressure rated 6/10. The nurse gives nitroglycerin 0.4 mg sublingually, prescribed every 5 minutes up to 3 doses for chest pain. At 1405 the client rates the pressure 5/10. The BP is 126/78 mm Hg, the heart rate is 96/min, and the SpO2 is 97% on room air. Which actions should the nurse take?

Accepted Answer

A: Give a second dose of nitroglycerin 0.4 mg sublingually; B: Notify the health care provider of the unrelieved chest pressure; D: Obtain a 12-lead ECG. Chest pressure in a hospitalized client is treated as possible myocardial ischemia until proven otherwise. Nitroglycerin dilates the veins, which lowers the amount of blood returning to the heart and the work the heart has to do, and it dilates the coronary arteries. Pain that is still present 5 minutes after the first tablet has not been relieved, even if it is a little less.

The systolic BP of 126 is well above 90 mm Hg, so the second dose is given now. A 12-lead ECG is obtained during the pain, ideally within 10 minutes of its onset, because ST changes during pain show whether the heart muscle is injured. Unrelieved chest pain in a hospitalized client is reported immediately to the health care provider, who can start the acute coronary syndrome pathway, and the rapid response team is called if the client becomes unstable.

Question 4

The nurse is preparing to administer phenytoin 100 mg IV every 8 hours to a 34-year-old client with a seizure disorder through a saline lock in the left forearm. The client is on a cardiac monitor, and 5% dextrose in water is infusing through a second IV site in the right arm. Place the following actions in the order the nurse should perform them.

Accepted Answer

1: Measure the client's apical pulse and BP before the dose; 2: Check the saline lock for a blood return and flush it with 0.9% sodium chloride; 3: Inject phenytoin slowly, no faster than 50 mg/min, while watching the cardiac monitor; 4: Flush the saline lock with 0.9% sodium chloride after the dose; 5: Inspect the IV site for redness, swelling, and discoloration of the hand and forearm. IV phenytoin is a strongly alkaline drug that is hard on the heart and the veins. Given too fast, it can cause hypotension, bradycardia and life-threatening dysrhythmias, so the adult rate is never faster than 50 mg/min, about 2 minutes for this dose, with the client on a monitor. It precipitates into crystals in any solution containing dextrose, which is why it goes through the saline lock and never through the line running 5% dextrose in water.

The order follows the drug. A baseline pulse and BP come first, so the nurse can recognize a drop during the injection. The saline lock is then checked for a blood return and flushed with 0.9% sodium chloride, which confirms the catheter is in the vein and clears the line. The phenytoin goes in slowly with the nurse watching the monitor, and a second saline flush pushes the rest of the dose through and keeps the drug out of contact with anything else. Last, the nurse inspects the site, because phenytoin that leaks into the tissue causes pain, swelling and a bluish discoloration of the hand that can progress to tissue death.

Question 5

The nurse in the intensive care unit is caring for a 41-year-old client with a traumatic brain injury and an intraventricular catheter. The blood pressure is 108/57 mm Hg and the intracranial pressure is 22 mm Hg. What is the client's cerebral perfusion pressure in mm Hg? Record your answer using a whole number.

Accepted Answer

52. Cerebral perfusion pressure (CPP) is the pressure that pushes blood into the brain. It is the mean arterial pressure (MAP) minus the intracranial pressure (ICP), because the pressure inside the skull pushes back against the blood coming in. The usual goal after a brain injury is a CPP of 60 to 70 mm Hg or higher.

This client's CPP is 52 mm Hg. Two problems are working together: the ICP is above 20 and the MAP is low. A CPP under 60 means parts of the brain are not getting enough blood, so the nurse reports it, and the team works on both sides of the equation, lowering the ICP and supporting the MAP with fluid or a vasopressor as prescribed.

Question 6

Two weeks after a myocardial infarction (MI), a 62-year-old client attends a cardiac rehabilitation class. The nurse teaches the client about a Mediterranean eating pattern. Which statement by the client indicates a need for further teaching?

Accepted Answer

A: "I will cook with coconut oil because it comes from a plant.". Myocardial infarction is death of heart muscle caused by prolonged blockage of coronary blood flow. It can reduce pumping and trigger life-threatening arrhythmias, heart failure or shock.

Coconut oil comes from a plant but is very high in saturated fat, which raises low-density lipoprotein (LDL) cholesterol. The Mediterranean pattern uses olive oil as the main fat. It is rich in vegetables, fruit, whole grains, legumes, nuts and fish, and it limits red and processed meat and sweets. This pattern lowers the risk of another cardiac event.

Question 7

A nurse is caring for a client whose morning potassium has come back at 6.5 mEq/L with changes on the cardiac monitor. Which of the following describes what the nurse should do?

Accepted Answer

B: Stay with the client while a colleague brings the prescribed treatment. A result at the very top of the ranking is the one where the nurse does not leave the room. A potassium above 6 with a changed monitor trace is that result, because the rhythm can deteriorate in minutes and the person who notices is the person standing there.

Everything else is delegated outward. A colleague fetches the drug, a colleague makes the telephone call, a colleague brings the monitor. The nurse stays.

That is worth separating from the very common situation one step down, where an action is needed now but the client is not about to arrest. There the nurse acts and moves on. Here the nurse acts and stays.

Question 8

The nurse has taught a 61-year-old client recovering from a myocardial infarction to limit saturated fat to less than 6% of daily calories. Which of the following statements by the client would require follow-up?

Accepted Answer

B: "I switched to coconut oil for cooking, since it comes from a plant."; D: "Whole milk is fine to keep drinking, because dairy is good for my bones.". Myocardial infarction is death of heart muscle caused by prolonged blockage of coronary blood flow.

Saturated fat raises LDL cholesterol more than any other part of the diet, and after a myocardial infarction the goal is to keep it under about 6% of calories. Most saturated fat comes from animal foods, but a few plant oils are just as saturated.

Coconut oil is about 85% saturated fat, more than butter, so a plant source does not make it heart healthy. Whole milk is a major source of saturated fat, and fat-free or 1% milk provides the same calcium and protein.

Question 9

A 66-year-old client with acute kidney injury has a potassium of 6.8 mEq/L, and the cardiac monitor shows peaked T waves. The health care provider prescribes calcium gluconate 1 g IV over 10 minutes. A sodium bicarbonate infusion is running through the client's only peripheral IV. Which of the following actions should the nurse take?

Accepted Answer

A: Stop the sodium bicarbonate and flush the line before and after the calcium gluconate; C: Confirm that the IV site is patent and watch it closely for signs of infiltration; D: Keep the client on continuous cardiac monitoring during and after the dose. Calcium gluconate is the first medication given for hyperkalemia with ECG changes. It does not lower the potassium at all. It restores the normal difference between the resting and threshold potentials of the heart muscle cells, which protects the heart from dysrhythmias within minutes. The effect lasts only 30 to 60 minutes, so other medications that move potassium into the cells and out of the body follow.

Because the heart is the reason for the medication, the client stays on continuous cardiac monitoring, and the nurse watches for the T waves to settle and for bradycardia. Calcium is irritating to veins and causes tissue injury if it leaks, so the site must be patent and watched closely. Calcium and bicarbonate form calcium carbonate, a precipitate, so they are never mixed. The nurse stops the bicarbonate and flushes the line before and after the dose, or uses a separate line.

Question 10

A client is admitted with rapid atrial fibrillation and the health care provider prescribes a continuous intravenous infusion for rate control. Which medication should the nurse anticipate?

Accepted Answer

D: Diltiazem. Diltiazem is the calcium channel blocker given as a continuous intravenous drip, and rate control in rapid atrial fibrillation is exactly what it is used for. It slows conduction through the atrioventricular node, so fewer of the chaotic atrial impulses reach the ventricles and the ventricular rate comes down.

Being able to run it as an infusion is what makes it useful here. The rate can be titrated up or down against the client's response minute by minute, which an oral tablet cannot do in a client who is unstable.

Cardiac practice questions.