NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 6

LESSON TITLE: Coronary Atherosclerosis/Coronary

Arterial Disease and Heart Failure/Congestive Heart
Failure
LEARNING TARGETS:
Materials: MS notebook, paper, pen, index card,
At the end of the lesson, the student nurses will be to: and bond paper (short & long size)

1. Identify risk factors of coronary atherosclerosis and References:

coronary arterial disease; Smeltzer S.C., & Bare B.G. (2010) Brunner and
2. Define heart failure and classify types of heart failure Suddarth’s Textbook of Medical- Surgical Nursing.
3. Explain the clinical manifestation, diagnostic finding Lippincott William & Wilkins
and identify preventive measures of the disease;
4. Outline nursing process in caring clients experiencing Sommer S., Johnson J. (2013) RN Adult Medical
the disease; and, Surgical Nursing. Assessment Technology
5. Illustrate nursing management of patients with the Institute, LLC.
disease condition. https://www.nurseslab.com

LESSON PREVIEW/REVIEW (15 minutes)

Instruction: Enumerate and describe the types of Pneumothorax.

1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________

MAIN LESSON (60 minutes)

The instructor should discuss the following topics. Instruct students to take down notes and read their book about this
lesson (Chapter 30 of the book).

Coronary atherosclerosis is the most common cause of cardiovascular disease in the United States and is
characterized by an abnormal accumulation of lipid or fatty substances and fibrous tissue in the vessel wall. These
substances block or narrow the vessel, reducing blood flow to the myocardium.

Atherosclerosis involves a repetitious inflammatory response to injury of the artery wall and subsequent alteration in the
structural and biochemical properties of the arterial walls.
Modifiable Not Modifiable
Risk Factors
 High blood cholesterol  Positive family history (a first-degree
(hyperlipidemia) relative with cardiovascular disease at
 Cigarette smoking, tobacco use age 55 years or younger for males and at
 Elevated blood pressure age 65 years or younger for females)
 Hyperglycemia (diabetes mellitus)  Age (more than 45 years for men, more
 Metabolic syndrome than 55 years for women)
 Obesity  Gender (men develop cardiovascular
 Physical inactivity disease
 Race (higher incidence in African
Americans)

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Education (Department of Nursing) 1 of 10
Clinical Manifestations
Symptoms and complications develop according to the location and degree of narrowing of the arterial lumen, thrombus
formation, and obstruction of blood flow to the myocardium.

Symptoms include the following:

 Ischemia
 Chest pain: angina pectoris
 Atypical symptoms of myocardial ischemia (shortness of breath, nausea, and weakness)
 Myocardial infarction
 Dysrhythmias, sudden death

Assessment and Diagnostic Methods
 Identification of risk factors for coronary heart disease (CHD) primarily involves taking a thorough history,
including family history, physical examination (note blood pressure and weight)
 Laboratory work (e.g., cholesterol levels [low-density lipoprotein (LDL) to high-density lipoprotein (HDL)],
glucose).

Prevention
The major management goal is prevention of CHD.
 Four modifiable risk factors—cholesterol abnormalities, tobacco use, hypertension, and diabetes mellitus—have
been cited as major risk factors for CAD and its complications. As a result, they receive much attention in health
promotion programs.

Medical Management
 The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and
to increase the oxygen supply.
 Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively,
reperfusion procedures may be used to restore the blood supply to the myocardium.
 These include PCI procedures (e.g., percutaneous transluminal coronary angioplasty [PTCA], intracoronary
stents, and atherectomy) and coronary artery bypass graft (CABG).

Nursing Management
A. Assessment
 Gather information about the patient’s symptoms and activities, especially those that precede and precipitate
attacks of angina pectoris. In addition, assess the patient’s risk factors for CAD, the patient’s response to angina,
the patient’s and family’s understanding of the diagnosis, and adherence to the current treatment plan.

B. Diagnosis Nursing Diagnoses

 Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or other prodromal symptoms
 Death anxiety
 Deficient knowledge about underlying disease and methods for avoiding complications
 Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle
changes

C. Collaborative Problems/Potential Complications

 Potential complications of angina include ACS and/or MI, dysrhythmias and cardiac arrest, heart failure, and
cardiogenic shock.

D. Planning and Goals

 Goals include immediate and appropriate treatment when angina occurs, prevention of angina, reduction of
anxiety, awareness of the disease process and understanding of the prescribed care, adherence to the self-care
program, and absence of complications.

E. Nursing Interventions Treating Angina

 Take immediate action if patient reports pain or if the person’s prodromal symptoms suggest anginal ischemia
 Direct the patient to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen
requirements of the ischemic myocardium

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Education (Department of Nursing) 2 of 10
  . Measure vital signs and observe for signs of respiratory distress.
 Administer nitroglycerin sublingually and asses the patient’s response (repeat up to three doses).
 Administer oxygen therapy if the patient’s respiratory rate is increased or if the oxygen saturation level is
decreased.
 If the pain is significant and continues after these interventions, the patient is further evaluated for acute MI and
may be transferred to a higher-acuity nursing unit.

Teaching Patients Self-Care

 The teaching program for the patient with angina is designed so that the patient and family understand the illness,
identify the symptoms of myocardial ischemia, state the actions to take when symptoms develop, and discuss
methods to prevent chest pain and the advancement of CAD.
 The goals of education are to reduce the frequency and severity of anginal attacks, to delay the progress of the
underlying disease if possible, and to prevent complications.
 Collaborate on a self-care program with patient, family, or friends.
 Plan activities to minimize angina episodes
 Teach patient that any pain unrelieved within 15 minutes by the usual methods, including nitroglycerin, should be
treated at the closest emergency center. Patient should call 911 for assistance.

F. Evaluation Expected Patient Outcomes

 Reports that pain is relieved promptly
 Reports decreased anxiety
 Understands ways to avoid complications and demonstrates freedom from complications
 Complies with self-care program

Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and
symptoms of fluid overload or of inadequate tissue perfusion.
Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
The term heart failure indicates myocardial disease in which there is a problem with contraction of the heart (systolic
dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or systemic congestion.
Heart failure is most often a progressive, life-long condition that is managed with lifestyle changes and medications to
prevent episodes of acute decompensated heart failure.

Classification
Heart failure is classified into two types: left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

 Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure.
 Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the
aorta and the systemic circulation.
 Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the
pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange.

Right-Sided Heart Failure

 When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates. The right side of
the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous
circulation. Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the
venous system.

Stages of Heart Failure:

1. Stage A. Patients at high risk for developing left ventricular dysfunction but without structural heart disease or
symptoms of heart failure.
2. Stage B. Patients with left ventricular dysfunction or structural heart disease that has not developed symptoms of
heart failure.
3. Stage C. Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of
heart failure.
4. Stage D. Patients with refractory end-stage heart failure requiring specialized interventions.

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Education (Department of Nursing) 3 of 10
Pathophysiology
 Heart failure results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery
disease, and valvular disease. As HF develops, the body activates neurohormonal compensatory mechanisms.
 Systolic HF results in decreased blood volume being ejected from the ventricle.
 The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine.
 Decrease in renal perfusion causes renin release, and then promotes the formation of angiotensin I.
 Angiotensin I is converted to angiotensin II by ACE which constricts the blood vessels and stimulates aldosterone
release that causes sodium and fluid retention.
 There is a reduction in the contractility of the muscle fibers of the heart as the workload increases.

Compensation
Heart failure results from a variety of cardiovascular conditions, including.
 The heart compensates for the increased workload by increasing the thickness of the heart muscle.
 Heart failure can affect both women and men, although the mortality is higher among women.

There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites.
Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65. It is also the leading cause
of hospitalization in older people.

Causes
Systemic diseases are usually one of the most common causes of heart failure.
 Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary
artery disease is found in more than 60% of the patients with HF.
 Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid.
 Cardiomyopathy. HF due to cardiomyopathy is usually chronic and progressive.
 Systemic or pulmonary hypertension. Increase in afterload results from hypertension, which increases the
workload of the heart and leads to hypertrophy of myocardial muscle fibers.
 Valvular heart disease. Blood has increasing difficulty moving forward, increasing pressure within the heart and
increasing cardiac workload.

Clinical Manifestations

Left-sided HF
 Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.
 Cough. The cough associated with left ventricular failure is initially dry and nonproductive.
 Pulmonary crackles. Bibasilar crackles are detected earlier and as it worsens, crackles can be auscultated across
all lung fields.
 Low oxygen saturation levels. Oxygen saturation may decrease because of increased pulmonary pressures.
Right-sided HF
 Enlargement of the liver result from venous engorgement of the liver.
 Accumulation of fluid in the peritoneal cavity may increase pressure on the stomach and intestines and cause
gastrointestinal distress.
 Loss of appetite results from venous engorgement and venous stasis within the abdominal organs.
Prevention
Prevention of heart failure mainly lies in lifestyle management.
 Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual.
 Engaging in cardiovascular exercises thrice a week could keep the cardiovascular system up and running
smoothly.
 Smoking cessation. Nicotine causes vasoconstriction that increases the pressure along the vessels.

Complications
Many potential problems associated with HF therapy relate to the use of diuretics.
 Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.
 Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or spironolactone.
 Prolonged diuretic therapy might lead to hyponatremia and result in disorientation, fatigue, apprehension,
weakness, and muscle cramps.
 Dehydration and hypotension. Volume depletion from excessive fluid loss may lead
to dehydration and hypotension.

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Education (Department of Nursing) 4 of 10
Assessment and Diagnostic Findings
HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema.
 ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present.
Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent
premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and
decreased QRS amplitude may be present.
 Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood
vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may
suggest ventricular aneurysm.
 Sonograms (echocardiography, Doppler and transesophageal echocardiography): May reveal enlarged chamber
dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
 Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole,
measures ejection fraction, and estimates wall motion.
 Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan):Determines presence
of myocardial ischemia and wall motion abnormalities.
 Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable
myocardium.
 Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart
failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected
into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous
endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis
or amyloidosis.
 Liver enzymes: Elevated in liver congestion/failure.
 Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.
 Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
 Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
 Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive
pulmonary disease (COPD) or chronic HF.
 Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or
hypoxemia with an increased Pco2 (late).
 BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is
indicative of renal failure.
 Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in
congested liver.
 Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention.
Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory
or infectious states.
 ESR: May be elevated, indicating acute inflammatory reaction.
 Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

Medical Management
 The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality
of life, and to extend survival.

Pharmacologic Therapy
 ACE Inhibitors. ACE inhibitors slow the progression of HF, improve exercise tolerance, decrease the number of
hospitalizations for HF, and promote vasodilation and diuresis by decreasing afterload and preload.
 Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I at the angiotensin II receptor and
cause decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output.
 Beta Blockers. Beta blockers reduce the adverse effects from the constant stimulation of the sympathetic
nervous system.
 Diuretics. Diuretics are prescribed to remove excess extracellular fluid by increasing the rate of urine produced in
patients with signs and symptoms of fluid overload.
 Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic vascular resistance but
contraindicated in patients with systolic HF.

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Education (Department of Nursing) 5 of 10
Nutritional Therapy
 Sodium restriction. A low sodium diet of 2 to 3g/day reduces fluid retention and the symptoms of peripheral and
pulmonary congestion, and decrease the amount of circulating blood volume, which decreases myocardial work.
 Patient compliance. Patient compliance is important because dietary indiscretions may result in severe
exacerbations of HF requiring hospitalizations.

Additional Therapy
 Supplemental Oxygen. The need for supplemental oxygen is based on the degree of pulmonary congestion and
resulting hypoxia.
 Cardiac Resynchronization Therapy. CRT involves the use of a biventricular pacemaker to treat electrical
conduction defects.
 Ultrafiltration. Ultrafiltration is an alternative intervention for patients with severe fluid overload.
 Cardiac Transplant. For some patients with end-stage heart failure, cardiac transplant is the only option for long
term survival.

Nursing Management
Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses have a major impact on outcomes
for patients with HF.

A. Nursing Assessment
The nursing assessment for the patient with HF focuses on observing for the effectiveness of therapy and for the patient’s
ability to understand and implement self-management strategies.
 Health History
 Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue, and edema.
 Assess for sleep disturbances, especially sleep suddenly interrupted by shortness of breath.
 Explore the patient’s understanding of HF, self-management strategies, and the ability and willingness to adhere
to those strategies.

B. Physical Examination
Auscultate the lungs for presence of crackles and wheezes.
 Auscultate the heart for the presence of an S3 heart sound.
 Assess JVD for presence of distention.
 Evaluate the sensorium and level of consciousness.
 Assess the dependent parts of the patient’s body for perfusion and edema.
 Assess the liver for hepatojugular reflux.
 Measure the urinary output carefully to establish a baseline against which to assess the effectiveness of diuretic
therapy.
 Weigh the patient daily in the hospital or at home.

C. Diagnosis
Based on the assessment data, major nursing diagnoses for the patient with HF include the following.
 Activity intolerance related to decrease CO.
 Excess fluid volume related to the HF syndrome.
 Anxiety related to breathlessness from inadequate oxygenation.
 Powerlessness related to chronic illness and hospitalizations.
 Ineffective therapeutic regimen management related to lack of knowledge.

D. Planning & Goals

The care plan necessary for HF focuses on:
 Promoting physical activities.
 Reducing fatigue.
 Relieving fluid overload symptoms.
 Decreasing anxiety.
 Increasing the patient’s ability to manage anxiety.
 Encouraging the patient to verbalize his or her ability to make decisions and influence outcome.
 Teaching the patient about self-care program.

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Education (Department of Nursing) 6 of 10
E. Nursing Interventions
Nursing interventions for a patient with HF focuses on management of the patient’s activities and fluid intake.
 Promoting activity tolerance. A total of 30 minutes of physical activity every day should be encouraged, and
the nurse and the physician should collaborate to develop a schedule that promotes pacing and prioritization of
activities.
 Managing fluid volume. The patient’s fluid status should be monitored closely, auscultating the lungs, monitoring
daily body weight, and assisting the patient to adhere to a low sodium diet.
 Controlling anxiety. When the patient exhibits anxiety, the nurse should promote physical comfort and provide
psychological support, and begin teaching ways to control anxiety and avoid anxiety-provoking situations.
 Minimizing powerlessness. Encourage the patient to verbalize their concerns and provide the patient with decision-
making opportunities.
Nursing Priorities
1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

F. Evaluation
For the expected patient outcomes, the following are evaluated:
 Demonstration of tolerance for increased activity.
 Maintenance of fluid balance.
 Less anxiety.
 Decides soundly regarding care and treatment.
 Adherence to self-care regimen.

G. Discharge and Home Care Guidelines

 The nurse should provide education and involve the patient in the therapeutic regimen.
 Patient education. Teach the patient and their families about medication management, low-sodium diets, activity
and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of
worsening HF.
 Encourage the patient and their families to ask questions so that information can be clarified and understanding
enhanced.

CHECK FOR UNDERSTANDING (30 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

Multiple Choice

(For 1-15 items, please refer to the questions in the Rationalization Activity)

RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates for 20 minutes.

1. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates
to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders
include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The
nurse should first:
A. Administer morphine
B. Obtain 12 leads ECG
C. Obtain laboratory work
D. Order chest X-ray
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

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Education (Department of Nursing) 7 of 10
2. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the
drug when chest pain occurs?
A. Take one tablet every 2-5 minutes until pain stops.
B. Take one tablet and rest for 10 minutes. Call the physician if pain persist after 10 minutes.
C. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persist
after 3 tablets.
D. Take one tablet. If pain persist, after 5 minutes, take two tablets. If pain still persist 5 minutes later, call the
physician.
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

3. A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the
physician’s office. The nurse would plan on having which of the following medications readily available for use?
A. Diltiazem ( Cardizem
B. Digoxin ( Lanoxin)
C. Propranolol ( Inderal)
D. Metoprolol ( Lopressor)
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following
disorders reported by the client is unlikely to play a role in exacerbating the heart failure?
A. Recent URI
B. Nutritional anemia
C. Peptic ulcer disease
D. A-fib
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram
complexes on the screen. The first action of the nurse is to:
A. Check the client status and lead placement.
B. Press the recorder button on the electrocardiogram console.
C. Call the physician.
D. Call a code blue
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

6. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?
A. Heart failure
B. Diabetes
C. MI
D. Pericardial effusion
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that
apply.
A. Reflects electrical impulse beginning at the SA node

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Education (Department of Nursing) 8 of 10
 B. Indicated electrical impulse beginning at the AV node.
C. Reflects atrial muscle depolarization
D. Identifies ventricular muscle depolarization
E. Has duration normally of 0.11 seconds or less.
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

8. Which of the following arteries primarily feeds the anterior wall of the heart?
A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

9. With which of the following disorders is jugular vein distention most prominent?
A. Abdominal aortic aneurysm
B. Heart failure
C. MI
D. Pneumothorax
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following
conditions?
A. Pericarditis
B. Hypertension
C. MI
D. Heart Failure
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

11. Which of the following factors can cause blood pressure to drop to normal levels?
A. Kidney’s excretion of sodium only
B. Kidney’s retention of sodium and water
C. Kidney’s excretion of sodium and water
D. Kidney’s retention of sodium and excretion of water.
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

12. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that
this procedure is being used in this specific case to:
A. Open and dilate the blocked coronary arteries.
B. Assess the extent of arterial blockage
C. Bypass obstructed vessels
D. Assess the functional adequacy of the valves and heart muscles.
ANSWER: ________

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Education (Department of Nursing) 9 of 10
 RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

13. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given
sublingually. This drug’s principal effects are produced by:
A. Antispasmodic effect on the pericardium
B. Causing an increased myocardial oxygen demand
C. Vasodilation of peripheral vasculature
D. Improved conducting in the myocardium.
ANSWER: ________
RATIO:________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________

14. Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to
see evidence of the drugs desired effect?
A. 5 to 10 minutes
B. 30 to 60 minutes
C. 2-4 hours
D. 6-8 hours
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

15. Which of the following symptoms is most commonly associated with left-sided heart failure?
A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension
ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________

3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 10 of 10
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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11. ANSWER: ________

RATIO:_______________________________________________________________________________________
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12. ANSWER: ________

RATIO:_______________________________________________________________________________________
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13. ANSWER: ________

RATIO:_______________________________________________________________________________________
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14. ANSWER: ________

RATIO:_______________________________________________________________________________________
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15. ANSWER: ________

RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 11 of 10
LESSON WRAP-UP (15 minutes)

Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

AL Strategy: Small Group Discussion/ Sharing

Instruction: You need to form groups of four as you will be asked to discuss answers to the question given by the
Instructor. You we’re given prior instruction on the materials needed (manila paper/ pentel pen) so that you can write your
answer to it. All groups will be given 4-5 minutes to discuss and answer all the questions.

(For Related Learning Experience, please refer to your clinical instructor.)

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Education (Department of Nursing) 12 of 10