Care of Patients with Acute Coronary Syndromes
(Concepts for Interprofessional Collaborative Care
, Care of Patients with Acute Coronary Syndromes
(Concepts for Interprofessional Collaborative Care
Chapter 38: Care of Patients with Acute Coronary Syndromes
MULTIPLE CHOICE
1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be
disoriented to person, place, and time. What action by the nurse is best?
a. Assess the clients pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
ANS: C
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse
should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses
and vital signs, occurs next. The nurse may or may not need to call a neurologist.
2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an
intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response
by the nurse is best?
a. The t-PA didnt dissolve the entire coronary clot.
b. The heparin keeps that artery from getting blocked again.
c. Heparin keeps the blood as thin as possible for a longer time.
d. The heparin prevents a stroke from occurring as the t-PA wears off.
ANS: B
After the original intracoronary clot has dissolved, large amounts of thrombin are released into the
bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is
not a blood thinner, although laypeople may refer to it as such.
DIF: Understanding/Comprehension REF: 779
KEY: Coronary artery disease| thrombolytic agents| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse
assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and
respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.
ANS: B
This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to
continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.
4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the
client states nothing is wrong and yet listens attentively while the student provides education on lifestyle
changes and healthy menu choices. What response by the faculty member is best?
(Concepts for Interprofessional Collaborative Care
, Care of Patients with Acute Coronary Syndromes
(Concepts for Interprofessional Collaborative Care
Chapter 38: Care of Patients with Acute Coronary Syndromes
MULTIPLE CHOICE
1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be
disoriented to person, place, and time. What action by the nurse is best?
a. Assess the clients pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
ANS: C
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse
should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses
and vital signs, occurs next. The nurse may or may not need to call a neurologist.
2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an
intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response
by the nurse is best?
a. The t-PA didnt dissolve the entire coronary clot.
b. The heparin keeps that artery from getting blocked again.
c. Heparin keeps the blood as thin as possible for a longer time.
d. The heparin prevents a stroke from occurring as the t-PA wears off.
ANS: B
After the original intracoronary clot has dissolved, large amounts of thrombin are released into the
bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is
not a blood thinner, although laypeople may refer to it as such.
DIF: Understanding/Comprehension REF: 779
KEY: Coronary artery disease| thrombolytic agents| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse
assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and
respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.
ANS: B
This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to
continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.
4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the
client states nothing is wrong and yet listens attentively while the student provides education on lifestyle
changes and healthy menu choices. What response by the faculty member is best?
