Perfusion

A patient diagnosed with mild heart failure is prescribed hydrochlorothiazide (Microzide). The healthcare provider should determine the teaching about the medication has been successful if the patient makes which of these statements?

• "I should not worry if I experience a dry cough when taking this medication."

• "It is important for me to change positions slowly because I might become dizzy."

• "This medication might cause me to have a decrease in appetite."

• "I might experience swelling in my legs when taking this medication."

A patient who has a history of artery stenosis tells the healthcare provider, “I don’t have a lot of energy anymore, and both of my feet get swollen in the late afternoon.” Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?

• left sided heart failure

• hypovolemia

• peripheral artery disease

• right sided heart failure

A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review?

• sodium

• troponin

• potassium

• BUN

A patient has been admitted to the cardiac unit with a diagnosis of right sided heart failure. Which of the following assessment findings would the healthcare provider expect to observe?

• fatigue and hemoptysis

• bradycardia and cyanosis

• dyspnea and pulmonary crackles

• peripheral edema and jugular vein distension

A patient is being assessed for possible heart failure. Which of these laboratory results will provide support this diagnosis?

• decreased sodium

• increased creatinine

• decreased CRP

• increased BNP

When obtaining a health history of a patient admitted with a diagnosis of heart failure, which statement made by the patient supports the diagnosis of heart failure?

• "I get hot and break out in a sweat during the night."

• "I get out of breath when I go up a flight of stairs."

• "I sometimes feel pain in the middle of my chest during exercise"

• "I often feel pain in my lower legs when I talk a walk."

When assessing a patient with chronic heart failure, the healthcare provider would expect to identify which of these clinical manifestations?

• expiratory wheezing

• asymmetrical chest expansion

• subcutaneous crepitus

• inspiratory crackles

Which of the following actions is the first priority of care for a patient exhibiting signs and symptoms of coronary artery disease?

• decrease anxiety

• enhance myocardial oxygenation

• administer sublingual nitroglycerin

• educate the patient about his symptoms

Answer explanation

Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. The desired effect is to decrease myocardial oxygen demand by decreasing ventricular stress. Drugs with negative inotropic properties can decrease perfusion to the already ischemic myocardium. A combination of nitrates and beta-blockers may have cumulative effects on cardiac output.

• Option A: Promote expression of feelings and fears. Let the patient/SO know these are normal reactions. Unexpressed feelings may create internal turmoil and affect self-image. Verbalization of concerns reduces tension, verifies the level of coping, and facilitates dealing with feelings. The presence of negative self-talk can increase the level of anxiety and may contribute to an exacerbation of angina attacks.

• Option C: Sublingual nitroglycerin is administered to treat acute angina, but the administration isn’t the first priority. Nitroglycerin has been the standard for treating and preventing anginal pain for more than 100 yr. Today it is available in many forms and is still the cornerstone of antianginal therapy.

• Option D: Although educating the client is important in care delivery, it is not a priority when a client is compromised. Discuss the pathophysiology of condition. Stress the need for preventing and managing anginal attacks. Patients with angina need to learn why it occurs and what they can do to control it. This is the focus of therapeutic management to reduce the likelihood of myocardial infarction and promote a healthy heart lifestyle.

Medical treatment of coronary artery disease includes which of the following procedures?

• cardiac catheterization

• coronary artery bypass graft surgery

• oral medication

• percutaneous coronary intervention

Answer explanation

Oral medication administration is a noninvasive, medical treatment for coronary artery disease. Nitrates should be given for pain relief after making sure there are no contraindications to nitrates like hypotension, RV failure, and consumption of phosphodiesterase inhibitors in the past 24-48 hours. High-dose statin therapy and beta-blockers should also be initiated early. P2Y12 inhibitors (prasugrel, ticagrelor, or prasugrel) should be started based on the patient profile.

• Option A: Cardiac catheterization isn’t a treatment, but a diagnostic tool. Cardiac catheterization (cardiac cath or heart cath) is a procedure to examine how well the heart is working. A thin, hollow tube called a catheter is inserted into a large blood vessel that leads to the heart.

• Option B: Coronary artery bypass surgery is an invasive treatment. Coronary artery bypass grafting (CABG) is a major surgical operation where atheromatous blockages in a patient’s coronary arteries are bypassed with harvested venous or arterial conduits. The bypass restores blood flow to the ischemic myocardium which, in turn, restores function, viability, and relieves anginal symptoms.

• Option D: Percutaneous transluminal coronary angioplasty is an invasive, surgical treatment. Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous coronary intervention (PCI) is a minimally invasive procedure to open blocked or stenosed coronary arteries allowing unobstructed blood flow to the myocardium. The blockages occur because of lipid-rich plaque within the arteries, diminishing blood flow to the myocardium.

Which of the following conditions is the predominant cause of angina?

• increased preload

• decreased afterload

• coronary artery spasm

• inadequate oxygen supply

Answer explanation

Inadequate oxygen supply to the myocardium is responsible for the pain accompanying angina. The heart is dependent on adequate oxygen supply for energy production to support contractility. At the cellular level, ischemia causes an increase in anaerobic glycolysis. This increases the levels of hydrogen, potassium, and lactate in the venous return of the ischemic or affected area of the myocardium.

• Option A: Increased preload would be responsible for right-sided heart failure. Increases in preload, as demonstrated through an elevated PCW, are seen in several conditions such as heart failure, mitral stenosis, and mitral regurgitation. At higher preloads, the heart also has an increased oxygen demand, further debilitating the already diseased heart. In cases of heart failure, eventually, the heart cannot keep up with the increased load, and deleterious ventricular remodeling and loss of function ensue.

• Option B: Decreased afterload causes increased cardiac output. Afterload is the force against which the ventricles must act in order to eject blood, and is largely dependent on the arterial blood pressure and vascular tone. Similarly, reducing afterload can increase cardiac output, especially in conditions where contractility is impaired.

• Option C: Coronary artery spasm is responsible for variant angina. Coronary artery vasospasm (CAVS) is a constriction of the coronary arteries that can cause complete or near-complete occlusion of the vessel. In 1959, Dr. Myron Prinzmetal described a different entity of angina than the classic Heberden’s angina which was originally described in 1772. This vasospastic disease can cause acute ischemia and present anywhere along the spectrum of angina from stable angina to acute coronary syndrome.