Normal Sinus Rhythm (NSR)

Definition: Normal sinus rhythm (NSR) refers to the heart rhythm originating from the sinoatrial (SA) node, the natural pacemaker of the heart. It indicates a healthy electrical conduction system.

Characteristics of Normal Sinus Rhythm:

1. Rate:
   • 60 to 100 beats per minute (bpm). This is the normal heart rate for adults.
2. Rhythm:
   • Regular rhythm. The intervals between beats (R-R intervals) are consistent.
3. P Waves:
   • Present and upright in leads I, II, and aVF. Each P wave is followed by a QRS complex.
4. PR Interval:
   • 0.12 to 0.20 seconds (3 to 5 small boxes). The PR interval is consistent throughout the rhythm.
5. QRS Complex:
   • 0.06 to 0.10 seconds (1.5 to 2.5 small boxes). The QRS complex is narrow, indicating normal conduction through the ventricles.
6. T Waves:
   • Follow the QRS complex and are typically upright in most leads.

Clinical Significance:

• NSR indicates that the heart is functioning normally, with an appropriate rate and rhythm.
• It is often used as a baseline for assessing other arrhythmias or cardiac conditions.
• Monitoring for changes from NSR can help detect various cardiac issues, such as atrial fibrillation, tachycardia, or bradycardia.

Summary:

Normal sinus rhythm is characterized by a heart rate of 60-100 bpm, a regular rhythm, present and upright P waves, a normal PR interval, and a narrow QRS complex. Recognizing NSR is essential for assessing cardiac health and identifying potential arrhythmias.

Components of the QRS Complex:

1. Q Wave: The first negative deflection after the P wave. It may not always be present.
2. R Wave: The first positive deflection in the QRS complex. This is usually the tallest part of the complex.
3. S Wave: The negative deflection that follows the R wave.

Characteristics of the QRS Complex:

• Duration:
  • The normal duration of the QRS complex is 0.06 to 0.10 seconds (or 1.5 to 2.5 small boxes on the ECG grid). A prolonged QRS (greater than 0.10 seconds) can indicate various conditions, such as a bundle branch block or ventricular hypertrophy.
• Amplitude:
  • The height of the QRS complex can vary, but a significant increase or decrease in amplitude may indicate underlying cardiac issues.

Steps to Measure the QRS Complex:

1. Identify the QRS Complex: Locate the QRS complex on the ECG tracing.
2. Count the Small Boxes:
   • Measure the width of the QRS complex in small boxes.
   • Multiply the number of small boxes by 0.04 seconds to convert to seconds.

Clinical Significance:

• Narrow QRS Complex: Generally indicates a normal conduction pathway (less than 0.10 seconds).
• Wide QRS Complex: May indicate problems such as:
  • Bundle branch block.
  • Ventricular rhythm (such as ventricular tachycardia).
  • Electrolyte imbalances.

Summary:

• The QRS complex is vital for understanding ventricular activity.
• It consists of the Q wave, R wave, and S wave.
• Measure its duration and amplitude to assess for potential cardiac conditions.

By recognizing and interpreting the QRS complex accurately, nurses can provide valuable information regarding a patient's cardiac health.

Steps to Calculate the PR Interval:

1. Locate the P Wave: Identify the beginning of the P wave, which represents atrial depolarization.
2. Find the Start of the QRS Complex: Determine where the QRS complex begins. This is the start of ventricular depolarization.
3. Measure the PR Interval:
   • Use a caliper or ruler: If you have a printed ECG, you can use a caliper to measure the distance between the beginning of the P wave and the beginning of the QRS complex.
   • Count the small boxes: On the ECG grid, each small box typically represents 0.04 seconds. Count the number of small boxes between the P wave and the start of the QRS complex.
   • Calculate the time: Multiply the number of small boxes by 0.04 seconds to get the PR interval in seconds.

Example:

• If the PR interval spans 3 small boxes:
  • PR Interval = 3 boxes × 0.04 seconds = 0.12 seconds.

Normal PR Interval Range:

• The normal PR interval is typically between 0.12 to 0.20 seconds (or 3 to 5 small boxes).

Summary:

• Identify the P wave and QRS complex.
• Measure the distance between them in small boxes.
• Multiply by 0.04 seconds to determine the PR interval in seconds.

This information helps assess for conditions such as first-degree AV block or other conduction abnormalities.

Steps to Calculate Ventricular Rate:

1. Identify the R Waves: Look at the ECG strip and find the R waves, which represent ventricular depolarization.
2. Count the R Waves: Count the number of R waves in a specific time frame. Typically, you can use a 6-second strip for a quick estimate.
3. Multiply by 10: To find the ventricular rate per minute, multiply the number of R waves counted in the 6-second strip by 10.

Example:

• If you count 8 R waves in a 6-second strip:
  • Ventricular Rate = 8 R waves × 10 = 80 beats per minute (bpm).

Alternative Method (if using a longer strip):

1. Count the R Waves: Count the R waves in a longer strip (like 30 seconds or 1 minute).
2. Calculate the Rate:
   • For a 30-second strip, multiply the count by 2.
   • For a full minute, the count is the ventricular rate.

Summary:

• 6-second strip: Count R waves and multiply by 10.
• 30-second strip: Count R waves and multiply by 2.
• 1-minute strip: Count R waves directly.

This method helps assess the ventricular rate, which is important for diagnosing conditions like bradycardia, tachycardia, or irregular rhythms.

Steps to Calculate Atrial Rate:

1. Identify the P Waves: Look at the ECG strip and find the P waves, which represent atrial depolarization.
2. Count the P Waves: Count the number of P waves in a specific time frame. Typically, you'll look at a 6-second strip (which usually corresponds to 30 small squares on the ECG paper).
3. Multiply by 10: To find the atrial rate per minute, multiply the number of P waves you counted in the 6-second strip by 10.

Example:

• If you count 8 P waves in a 6-second strip:
  • Atrial Rate = 8 P waves × 10 = 80 beats per minute (bpm).

Alternative Method (if using a longer strip):

1. Count the P Waves: Count the P waves in a longer strip (like 30 seconds or 1 minute).
2. Calculate the Rate:
   • For a 30-second strip, multiply by 2.
   • For a full minute, the count is the atrial rate.

Summary:

• 6-second strip: Count P waves and multiply by 10.
• 30-second strip: Count P waves and multiply by 2.
• 1-minute strip: Count P waves directly.

This method allows for quick assessment of the atrial rate and can help in diagnosing conditions like atrial fibrillation or flutter.

The following information should be included in the teaching plan for a client with Raynaud phenomenon to help prevent a vasospastic attack:

• Avoid sudden changes in temperatures.
• Wear warm clothing when the temperature gets below 50°F (10°C).
• Use gloves when handling ice or frozen foods.
• Limit stressful situations.

While wearing hand splints may help with general comfort, it is not a primary prevention strategy for vasospastic attacks specifically.

The correct instruction for the client regarding the purpose of nitroglycerine cream is:

It promotes healing.

Nitroglycerine cream is used to improve blood flow to the area, which can help promote healing of ulcers associated with conditions like Raynaud phenomenon

For managing an attack of Raynaud phenomenon, the nurse should include the following information in the teaching plan:

• Go to a warm room. - This helps to increase overall body temperature and improve blood flow to the extremities.
• Move the fingers and toes. - Gentle movement can help promote circulation and reduce symptoms.
• Place hands under hot, running water. - This can help rewarm the hands and improve circulation.
• Massage the fingers and toes. - Gentle massage can stimulate blood flow to the affected areas.
• Place hands under the armpits. - This is also a way to use body heat to warm the hands.

All options listed (1 through 5) are appropriate strategies for managing an attack of Raynaud phenomenon.

For a client diagnosed with Raynaud phenomenon, the nurse should include the following instructions in the discharge plan:

• Stop smoking. - Smoking can exacerbate vascular issues and worsen Raynaud's symptoms.
• Wear a face covering and gloves in the winter. - Protecting the extremities from cold is essential to prevent Raynaud's attacks.
• Find employment that can be done in a warm environment. - A warmer environment will help minimize symptoms and prevent attacks.
• Report signs of orthostatic hypotension. - Reserpine can cause orthostatic hypotension, so it’s important to monitor for this side effect.

Note: Option 3, "Place fingertips in cool water to rewarm them," is not appropriate. Instead, the client should avoid cold exposure and use warm water for rewarming, if necessary.

The finding that warrants further evaluation is:

" an arterial blood pressure of 80/50 mm Hg "

This hypotensive reading indicates potential complications such as bleeding, inadequate circulation, or shock, which require immediate assessment and intervention. The other findings, while they may require monitoring, do not indicate an immediate crisis like the low blood pressure does.

The nurse should instruct the client to notify the health care provider (HCP) before having:

"tooth extraction"

This is important because a tooth extraction can lead to potential complications, such as bleeding or infection, especially in clients with a synthetic graft. The risk of endocarditis (infection of the heart lining) also increases with any procedure that can introduce bacteria into the bloodstream. Therefore, it's crucial to inform the HCP before undergoing such procedures.

The nurse should assess:

"decreased urinary output"

Following surgery for an aortic aneurysm repair, monitoring urinary output is crucial as it can indicate kidney function and possible complications such as hypovolemia or renal impairment. Decreased urinary output can be one of the first signs of issues that may arise postoperatively, making it a priority for assessment.

The nurse should assess the client for:

"cardiac tamponade."

A dissecting aortic aneurysm can lead to a rupture of the aorta, which may cause blood to accumulate in the pericardial sac, leading to cardiac tamponade. This is a life-threatening condition that requires immediate attention. While stroke and myocardial infarction are also potential complications, cardiac tamponade is particularly associated with the rupture of a dissecting aneurysm.

The nurse's primary goal at this time is:

Maintain circulation.

In the case of a large abdominal aortic aneurysm, the immediate concern is to maintain adequate circulation and prevent complications such as rupture or hypovolemic shock.

The unexpected finding that the nurse should report to the healthcare provider immediately is:

weakness and numbness in the lower extremities.

This could indicate potential complications such as ischemia or neurological deficits following the surgery and requires prompt evaluation.

The appropriate action for the nurse to take next is:

 Notify the surgeon.

If the client is not ready to sign the surgical consent form, it is essential to inform the surgeon. The surgeon can provide further information, address any concerns, or clarify details about the procedure to help the client make an informed decision. Consent must be informed and voluntary, so it’s crucial to ensure the client has all the information needed before proceeding.

In this scenario, the nurse should implement the prescriptions in the following order from first to last:

1. Establish an intravenous infusion.
   (This is the priority due to the client's hypotension and signs of shock, requiring immediate fluid resuscitation.)
2. Monitor intake and output.
   (Once IV access is established, it’s important to monitor the client's fluid status.)
3. Administer pain medication.
   (After addressing the immediate circulatory needs, pain management can be addressed to relieve the client’s discomfort.)
4. Insert a nasogastric tube.
   (This can be done after the more critical interventions to help decompress the stomach if necessary, but it is not as urgent as the other steps.)

This prioritization ensures that the most critical life-threatening issues are addressed first.

To determine the effectiveness of cilostazol for intermittent claudication, the nurse should ask:

"Do you have less pain in the legs?"

Cilostazol is primarily used to improve symptoms of intermittent claudication by enhancing blood flow to the extremities. Assessing for a reduction in leg pain during activities, such as walking, is a direct measure of the drug's effectiveness in treating this condition.

Before the right axillary-to-axillary artery bypass surgery, the nurse should take the following action:

Avoid using the right arm for venipuncture.

It's crucial to protect the right arm from any potential trauma or complications before surgery, especially since the procedure involves that area. Avoiding venipuncture in the right arm helps to minimize the risk of injury and preserves venous access for postoperative needs.

While assessing temperature, monitoring pulses, and protecting from cold are also important, avoiding venipuncture is a direct action that reduces risk before surgery.

The goal the nurse should establish with the client immediately after femoral-popliteal bypass surgery is:

 Maintain circulation.

Maintaining circulation is the highest priority after this type of surgery, as it is essential to ensure that the graft is functioning properly and that blood flow to the extremities is adequate. This includes monitoring peripheral pulses, skin color, temperature, and capillary refill.

While preventing infection, relieving pain, and providing education are also important goals, ensuring adequate circulation takes precedence immediately postoperatively.

The statement by the client that indicates a need for further instruction is:

"I should wipe any injury with iodine on a cotton ball."

This statement is concerning because using iodine can irritate the skin and may not be the best practice for cleaning wounds. Instead, the client should be instructed to clean injuries with mild soap and water and to seek medical advice for proper wound care.

The other statements are appropriate for managing peripheral artery disease:

1. "I won't use a heating pad." (to avoid burns due to decreased sensation)
2. "I'll sit in a chair with both of my legs on the floor." (to promote circulation)
3. "I'll wear leather shoes when I'm out of bed." (to protect the feet)

Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral artery disease.

When assessing a client who has just returned to the surgical care unit after femoral-popliteal bypass grafting, the findings should be prioritized as follows:

1. Peripheral pulses - Assessing peripheral pulses is critical to ensure that blood flow is adequate to the extremities and that the graft is functioning properly.
2. Incision site - Next, assess the incision site for any signs of bleeding, drainage, or infection, which can indicate complications.
3. Postoperative pain - After checking pulses and the incision site, assess the client’s pain level to manage discomfort effectively.
4. Urine output - Finally, evaluate urine output, which can be an indicator of overall perfusion and kidney function, although it is still important.

In this situation, the best first action for the nurse is:

Use a Doppler ultrasound device.

Using a Doppler ultrasound allows the nurse to assess the blood flow and determine whether the pulse is present but not palpable, rather than jumping to conclusions or making further assessments that might delay appropriate care.

If the Doppler confirms that there is no blood flow, the nurse can then proceed with further actions, such as inspecting the extremity or notifying the health care provider.

In a client with peripheral artery disease (PAD), you would expect to see the following findings:

2. Mottled skin - This can occur due to reduced blood flow and changes in circulation.
3. Coolness - The affected extremities often feel cooler than other parts of the body due to decreased blood supply.

The other options are generally not expected findings in PAD:

1. Hairy legs - Often, there is reduced hair growth on the legs due to inadequate blood supply.
2. Pink skin - The skin may appear pale or dusky rather than pink.
3. Moist skin - The skin may become dry and less hydrated due to poor circulation.

So, the correct findings to select are 2 (mottled skin) and 4 (coolness).

Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods. Cilostazol inhibits platelet aggregation induced by various stimuli and improves blood flow to the muscles, allowing the client to walk long distances without pain. Peripheral artery disease causes pain mainly in the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral artery disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body

Weakness, dizziness, and headache are common adverse effects of clopidogrel, and the client should report these to the health care provider (HCP) if they are problematic; to decrease the risk for clot formation, the drug must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of clopidogrel is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Clopidogrel is well absorbed, and while food may help decrease potential gastrointestinal upset, the drug may be taken with or without food. Clopidogrel is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome

With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, the nasal cannula setting, and capillary refill are important to assess; however, the priority is to determine the cause of the drop in blood pressure and that adequate perfusion through the new graft is maintained

An ankle-brachial index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with normal blood pressure. The SpO, is acceptable; the client has a smoking history.

Smoking and exposure to the cold cause vasoconstriction and should be avoided. Aspirin and clopidogrel should be taken as prescribed for the antiplatelet properties. Using extra bedclothes at night provides warmth, which increases vasodilation. The presence of pain should be investigated as it could indicate increasing arterial insufficiency. Tight socks should be avoided as they could impair circulation.

The nurse must have assessment data and verify vital signs if necessary to determine the action that is required. If there is a significant change in the client's condition, the charge nurse should be notified to help the nurse with both this client and the nurse's other assigned clients if necessary; most
acute care facilities have a rapid response team that can also help assess and intervene with basic standing prescriptions if necessary. Positioning the client in semi-Fowler's is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the nurse to reassure the client by staying calm and remaining with the client. The nurse must notify the HCP about the change in the client's condition; the nurse must have all information available and present it in a concise and accurate manner using SBAR format including a recommendation for treatment if indicated. The nurse should stay with this client and delegate checking on other assigned clients to the charge nurse or UAP.

After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin cardiopulmonary resuscitation promptly after cardiopulmonary arrest.

If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. A bag mask device allows for delivery of 100% oxygen but is difficult to manage if there is just one rescuer; ideally, two persons are used to operate the bag mask device, one to maintain the seal and the other to provide the ventilations. Compressions should be maintained at 100 per minute.

Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.

Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending. The client
should know how to count the pulse and do so daily or as instructed by the health care provider. The client will not necessarily be placed on a low-cholesterol diet. The client should resume activities and does not need to remain on bed rest. The client should know the signs and symptoms of an MI but is not at risk because of the pacemaker.

The spouse can have physical contact with the client, but if the ICD were to discharge while the spouse had contact with the client, the spouse would feel a "tingle" but would not be harmed. There is no warning device on the ICD

Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted.

The nurse must teach the client how to take and record the pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week after insertion. It takes up to 2 months for the incision site to heal and for full range of motion to return. The client should avoid heavy lifting until approved by the health care provider. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.

The nurse first should prepare the defibrillator for synchronized cardioversion. The client is experiencing PSVT with a heart rate of 180 bpm.
PSVT with a heart rate of 180 bpm causes a decrease in cardiac output. The client's vital signs and symptoms reveal the client is becoming hemodynamically unstable and require immediate intervention. Atropine is not a treatment for PSVT. CPR is not indicated for PSVT. Caffeine use can contribute to PSVT, but the client requires defibrillation now.

The client is showing signs of pneumothorax, a potential complication of pacemaker placement. The nurse should immediately assess the client's breath sounds and chest movement as this information will be important to share with the health care provider when notified. Assessing the insertion site and the client's blood pressure and pulse are important, but the nurse should first perform a focused respiratory assessment.

Because abnormalities in electrolytes are likely to affect the depolarization and repolarization
of cardiac cells, it is most important for the nurse to monitor sodium, potassium, and calcium levels. The
blood urea nitrogen is within normal range. Hemoglobin and hematocrit are not generally associated with cardiac dysrhythmias; the hemoglobin is within normal range. The PT and IN would be monitored closely on a client taking warfarin, not necessarily a client with cardiac dysrhythmia; the PT and IN are within normal range.

Warfarin is an anticoagulant used in clients with atrial fibrillation to reduce the risk for stroke or systemic embolization and, therefore, will put the client at risk for bleeding. The nurse should instruct the client to watch for signs of bleeding and prevent bruising. While good oral hygiene remains important, the nurse would advise against vigorous flossing and irritating the gums as it may increase the risk for bleeding. Warfarin does not affect the heart rate.

Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and, finally, coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.

Assessment of circulatory status, including observation of the puncture site, is of primary importance after cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

For clients scheduled for cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the health care
provider has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.

The ankle edema suggests fluid volume overload. The nurse should assess the respiratory rate, lung sounds, and oxygen saturation (Sp02) to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.

Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia,  nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.

In heart failure, the heart is unable to adequately meet the body's metabolic demands; in an attempt to supply major organs, less blood is circulated to extremities, leaving them cool, pale, and potentially cyanotic. A blood pressure of 102/64 mm Hg is lower than average, but it may be normal for this client and would not indicate poor perfusion of tissues. It is not unusual for the client with heart failure to have a slightly elevated heart rate (unless taking medications to lower the heart rate) because the increased rate may help compensate for reduced stroke volume (and therefore, decreased cardiac output). Shortness of breath may occur with heart failure as a result of poor pumping action of the heart that allows fluid to accumulate in the lungs; however, it is not an indicator of peripheral perfusion.

After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.

Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. The low Fowler position would be used if the client could not tolerate the high Fowler position for some reason. Lying on the right side would not be a good position for the client with heart failure. The client with heart failure would not tolerate the Trendelenburg position.

It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable

Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood
pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.

Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to a fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

The urinary output is less than the expected minimum of 30 mL per hour, and if the urinary output does not increase, the nurse who will next care for the client should report the decreased urinary output to the health care provider. An elevated B-type natriuretic peptide level is expected with acute heart failure. The level that the client can reach with the incentive spirometer is good to know, but it is not the most essential finding to report at this time. The admission weight is helpful only if a prior or baseline weight is also provided.

Simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take simvastatin in the evening, and the nurse should instruct the client that if a dose is missed, it should be taken as soon as remembered, but it should not be taken at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking warfarin), but the nurse should instruct the client to avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the HCP.

The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.

The nurse should instruct the client that the correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down
and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some HCPs may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes, and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the HCP.

Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and
exacerbate other symptoms, such as shortness of breath.

The client should report a change in the pattern of chest pain. It may indicate the increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a lowcholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol

Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs 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.

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

Cardiac arrhythmias are commonly observed with the administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with the administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue

The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after the onset of an MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.

The woman who is 65 years old, overweight, and with an elevated LDL level is at the greatest risk for CAD. Total cholesterol higher than 200 mg/dL (11.1 mmol/L); LDL higher than 100 mg/dL (5.5 mmol/L); HDL lower than 40 mg/ dL (2.2 mmol/L) in men; HDL lower than 50 mg/dL (2.8 mmol/L) in women; men 45 years and older; women 55 years and older; smoking; and obesity increase the risk for CAD. Atorvastatin reduces LDL and decreases the risk for CAD. The combination of being postmenopausal, having obesity, and having a high LDL level places this client at greatest risk.

Clopidogrel is generally well absorbed and may be taken with or without food; it should be taken at the same time every day, and, while food may help prevent potential gastrointestinal upset, food has no effect on the absorption of the drug. Bleeding is the most common adverse effect of clopidogrel;
the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding, including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of clopidogrel; the client should be aware of this possibility. Clopidogrel is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking clopidogrel.

Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk for pressure ulcer formation.

By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.

PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in a client who has experienced an MI, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic medication would not decrease ventricular irritability.

It is important for clients to wear hearing aids to this procedure so that they can hear the questions posed to them by the health care team. Chest pain often occurs when the balloon within the stent is inflated and deployed into the coronary artery. It is expected and brief but should still be reported by the client. During the procedure and for a prescribed amount of time after the procedure, the client will need to remain flat in bed with the right leg straight, not flexed, to prevent bleeding from the access site. The site is not routinely stitched. It is a puncture rather than an incision requiring sutures. The client may be given intravenous medication to help with comfort, but the client is kept awake to answer questions and to hear instructions and explanations. General anesthesia is not given.

IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability, and a beta-blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a pulmonary artery catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.

The nurse should first don gloves and apply direct pressure over the site to stop blood loss from the femoral artery. Although the nurse will later observe the site for further bleeding and record the extent of bleeding, this is not the first action that is needed. If the bleeding cannot be controlled, the HCP who performed the procedure should be contacted, but first, an attempt to manually stop the bleeding with direct pressure is warranted. Protamine sulfate is the antidote for heparin sodium, but this is not an initial action to control the bleeding.

Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

When preparing the client for a cardiac angiogram, the nurse should determine if the client has an allergy to the liquid contrast medium used in the procedure. Contrast dyes contain iodine, and the administration of a dye could lead to an anaphylactic response in clients who are allergic to the dye. An
intravenous infusion will be started before the procedure to administer the contrast dye. The client should not eat or drink for 8 hours prior to the procedure. The client may experience a flushing sensation, but this is a normal response and does not indicate a life-threatening reaction. The client may receive light sedation, but not an anesthetic as the client must be awake to follow instructions. The client should be instructed to remain still during the procedure.

The nurse should first assess the client's tolerance to the drop-in heart rate by checking the blood pressure and level of consciousness and determining if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done

Low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of leftsided heart failure. Crackles, edema, and weight gain should be monitored closely, but these levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.

Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear because of its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme inhibitor drugs, not morphine, may help prevent
ventricular remodeling

The nurse should first obtain vital signs because changes in the vital signs will reflect the severity of the sudden drop in cardiac output: a decrease in blood pressure, an increase in the heart rate, and an increase in the respiration rate. Infarction of the papillary muscles is a potential complication of an MI, causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space at the left midclavicular line. The murmur worsens during expiration and in the supine or left-side position and can best be heard when the client is in these positions, not with the client leaning forward. A 12-lead ECG views the electrical activity of the heart, an echocardiogram views valve function.

Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain, and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

The nurse should first contact the HCP and report the level of pain and recommend pain management that would help decrease myocardial oxygen demand. The nurse should monitor fluid status, but this is not the priority. The nurse can begin teaching the client about health management once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

The elevated troponin level should be reported to the HCP before the stress test because this change indicates myocardial damage. Sending the client to walk on a treadmill for stress testing would be contraindicated with evidence of recent myocardial injury and could further extend the damage. The other blood levels are helpful but not critical to this client's welfare at this point in time.