Troponin is a regulatory protein found in striated muscle.

The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band.

When performing cardiopulmonary resuscitation (CPR) on adults, the ratio of chest compressions to breaths is 30:2. Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms).

Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents The normal prothrombin time (PT) is 9.6 to 11.8 seconds suddenly with severe dyspnea accompanying the chest pain. (male adult) or 9.5 to 11.3 seconds (female adult). A Dissecting aortic aneurysms usually are accompanied by therapeutic PT level is 1.5 to 2.0 times higher than the normal back pain. level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the On transfer from the coronary care unit, the client is allowed client would not receive further doses at this time. self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. distances gradually increased (50, 100, 200 feet). A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The most important action is to notify the Metformin (Glucophage) needs to be withheld 48 hours physician, who may give further orders about holding further before and after cardiac catheterization because of the doses of digoxin. Option 3 is incorrect because the level is not injection of contrast medium during the procedure. If the normal. The next dose should not be administered because contrast medium affects kidney function, with metformin in the serum digoxin level exceeds the therapeutic range. the system, the client would be at increased risk for lactic Checking the clients last pulse rate is not incorrect but may acidosis. have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment Hypotension and dizziness are signs of decreased cardiac of the clients status may be more useful. output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the The normal activated partial thromboplastin time (aPTT) varies symptomatic client. Digoxin will further decrease the clients between 20 and 36 seconds, depending on the type of heart rate. Defibrillation is used for treatment of pulseless activator used in testing. The therapeutic dose of heparin for ventricular tachycardia and ventricular fibrillation. Continuing treatment of deep vein thrombosis is to keep the aPTT to monitor the client delays necessary intervention. between 1.5 and 2.5 times normal. Thus, the clients aPTT is within the therapeutic range, and the dose should remain Edema, the accumulation of excess fluid in the interstitial unchanged. spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in The normal serum potassium level in the adult is 3.5 to 5.1 the morning whenever possible to avoid nocturia. Strict mEq/L. Option 1 is the only value that falls below the sodium restrictions are reserved for clients with severe therapeutic range. Administering furosemide to a client with a symptoms. low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid Foods that are lower in sodium include fruits and vegetables disorders, pregnancy, Pagets disease, nutritional (option 4), because they do not contain physiological saline. deficiencies (thiamine, alcoholism), pulmonary disease, and Highly processed or refined foods (options 1 and 3) are higher hypervolemia. in sodium unless their food labels specifically state low sodium. Saltwater fish and shellfish are high in sodium. Digoxin exerts a positive inotropic effect on the heart while Fruits and vegetables tend to be lower in fat because they do slowing the overall rate through a variety of mechanisms. not come from animal sources. Fish is also naturally lower in Digoxin is the medication of choice to treat heart failure. fat. Cream cheese is a high-fat food. Diltiazem and verapamil (calcium channel blockers) and propranolol (-adrenergic blocker) have a negative inotropic When performing cardiopulmonary resuscitation (CPR) on an effect and would worsen the failing heart. adult client, the sternum is depressed 1 to 2 inches.

Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

Motion artifact, or noise, can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection.

Pulmonary edema causes the client to be extremely agitated Ventricular tachycardia is characterized by the absence of P and anxious. The client may complain of a sense of drowning, waves, wide QRS complexes (longer than 0.12 second), and suffocation, or smothering. typically a rate between 140 and 180 impulses/min. The rhythm is regular. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to Ventricular tachycardia is a life-threatening dysrhythmia that digoxin toxicity can occur in the client with hypokalemia. results from an irritable ectopic focus that takes over as the Hypokalemia also predisposes the client to ventricular pacemaker for the heart. The low cardiac output that results dysrhythmias. can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Classic signs of cardiogenic shock as they relate to this Ventricular tachycardia is treated with antidysrhythmic question include low blood pressure and tachycardia. The medications, cardioversion (client awake), or defibrillation central venous pressure would rise as the backward effects of (loss of consciousness). Ventricular tachycardia can the severe left ventricular failure became apparent. deteriorate into ventricular fibrillation at any time. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the First-line treatment of ventricular tachycardia in a client who myocardium. is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and Sternotomy incision sites are assessed for signs and symptoms procainamide (Pronestyl). Cardioversion also may be needed of infection, such as redness, swelling, induration, and to correct the rhythm (cardioversion is recommended for drainage. Elevated temperature and white blood cell count stable ventricular tachycardia). Defibrillation is used with after 3 to 4 days postoperatively usually indicate infection. pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is The client who undergoes cardiac surgery is at risk for renal contraindicated. injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by Cough cardiopulmonary resuscitation (CPR) sometimes is decreased urine output and increased blood urea nitrogen and used in the client with unstable ventricular tachycardia. The creatinine levels. The client may need medications to increase nurse tells the client to use cough CPR, if prescribed, by renal perfusion and possibly could need peritoneal dialysis or inhaling deeply and coughing forcefully every 1 to 3 hemodialysis. No data in the question indicate the presence of seconds. Cough CPR may terminate the dysrhythmia or hypovolemia, urinary tract infection, or glomerulonephritis. sustain the cerebral and coronary circulation for a short time until other measures can be implemented. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because The client with uncontrolled atrial fibrillation with a analgesia will promote rest, decrease myocardial oxygen ventricular rate more than 100 beats/min is at risk for low consumption resulting from pain, and allow better participation cardiac output because of loss of atrial kick. The nurse in activities such as coughing, deep breathing, and ambulation. assesses the client for palpitations, chest pain or discomfort, Options 2 and 4 will not help in tolerating ambulation. hypotension, pulse deficit, fatigue, weakness, dizziness, Removal of telemetry equipment is contraindicated unless syncope, shortness of breath, and distended neck veins. prescribed. Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria Normal sinus rhythm is defined as a regular rhythm, with an quiver, which can lead to thrombi formation. overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and Carotid sinus massage is one maneuver used for vagal 0.04 to 0.10 second, respectively. stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing Sinus tachycardia has the characteristics of normal sinus the gag reflex and asking the client to strain or bear down. rhythm, including a regular PP interval and normal width PR Medication therapy often is needed as an adjunct to keep and QRS intervals; however, the rate is the differentiating the rate down or maintain the normal rhythm. factor. In sinus tachycardia, the atrial and ventricular rates are higher than 100 beats/min.

Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. Until the defibrillator is attached and charged, the client is This procedure involves tying off the varicose vein and large resuscitated by using cardiopulmonary resuscitation. Once the tributaries and then removing the vein with hook and wires defibrillator has been attached, the electrocardiogram is via multiple small incisions in the leg. checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for Hypersensitivity or a sensation of pins and needles in the any loose connections. A nitroglycerin patch, if present, is surgical limb may indicate temporary or permanent nerve removed. The client does not have to be intubated to be injury following surgery. The saphenous vein and saphenous defibrillated. Lidocaine may be given subsequently but is not nerve run close together in the distal third of the leg. required before defibrillation. The machine is not set to the Because complications from this surgery are relatively rare, synchronous mode because there is no underlying rhythm with this symptom should be reported. which to synchronize. The mixture of arterial and venous manifestations The client may be defibrillated up to three times in succession. (claudication and phlebitis, respectively) in the young male The energy levels used are 200, 300, and 360 J for the first, client suggests thromboangiitis obliterans (Buergers second, and third attempts, respectively. disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found After defibrillation, the client requires continuous monitoring of in young adult males who smoke. The cause is not known electrocardiographic rhythm, hemodynamic status, and precisely but is suspected to have an autoimmune neurological status. Respiratory and metabolic acidosis component. develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and Raynauds disease responds favorably to eliminating caffeine cardiopulmonary complications. Arousable status, adequate from the diet and cessation of smoking. Medications may blood pressure, and a sinus rhythm indicate successful inhibit vessel spasm and prevent symptoms. Avoiding response to defibrillation. exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily The nurse or rescuer puts two large adhesive patch electrodes be beneficial because the symptoms still could occur with on the clients chest in the usual defibrillator positions. The the use of air conditioning and during periods of cooler nurse stops cardiopulmonary resuscitation and orders anyone weather. near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to After inferior vena cava filter insertion, the nurse inspects 30 seconds. The machine then indicates if defibrillation is the surgical site for bleeding and signs and symptoms of necessary infection. Otherwise, care is the same as for any other postoperative client. An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening An electrocardiogram taken during a chest pain episode episodes of ventricular tachycardia and ventricular fibrillation. captures ischemic changes, which include ST segment These devices are implanted in clients who are considered elevation or depression. Tall, peaked T waves may indicate high risk, including those who have survived sudden cardiac hyperkalemia. A prolonged PR interval indicates first-degree death unrelated to myocardial infarction, those who are heart block. A widened QRS complex indicates delay in refractive to medication therapy, and those who have syncopal intraventricular conduction, such as a bundle branch block. episodes related to ventricular tachycardia. This test is an alternative to the exercise thallium-201 scan. In the first several hours after insertion of a permanent or a Dipyridamole (Persantine) dilates the coronary arteries as temporary pacemaker, the most common complication is exercise would. Before the procedure, any form of caffeine pacing electrode dislodgement. The nurse helps prevent this should be withheld, as should bronchodilators such as complication by limiting the clients activities of the arm on the theophylline. Theophylline may decrease the effects of side of the insertion site. dipyridamole. Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. Blood pressure should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff

bladder should encircle at least 80% of the limb being measured. Finally, two or more BP readings should be Warfarin sodium works in the liver and inhibits synthesis of averaged. four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of Following pericardiocentesis, a rise in blood pressure and a fall warfarin is exhibited. in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer The antidote to warfarin sodium (Coumadin) is vitamin K muffled or distant. and should be readily available for use if excessive bleeding or hemorrhage occurs. Aminocaproic acid is the antidote for Not all clients with abdominal aortic aneurysm exhibit thrombolytic agents. Protamine sulfate is the antidote for symptoms. Those who do may describe a feeling of the heart heparin. Potassium chloride is administered to treat beating in the abdomen when supine or being able to feel the potassium deficit. mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be Thrombolytic therapy is contraindicated in a number of auscultated over the mass. Hyperactive bowel sounds are not preexisting conditions in which there is a risk of uncontrolled related specifically to an abdominal aortic aneurysm. bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe Following abdominal aortic aneurysm resection or repair, the uncontrolled hypertension because of the risk of cerebral nurse monitors the client for signs of renal failure. Renal hemorrhage. Therefore, the nurse would report the results failure can occur because often much blood is lost during the of the blood pressure to the physician before initiating surgery and, depending on the aneurysm location, the renal therapy. arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and The ACLS nurse would place one gel pad to the right of the notes the results of daily blood urea nitrogen and creatinine sternum just below the clavicle and the other gel pad to the levels. Urine output lower than 30 to 50 mL/hr is reported to left of the precordium. The nurse would then place the the physician. electrode paddles over the pads. Options 1, 3, and 4 identify incorrect positions. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The The client who has had vein ligation and stripping should edges of the ulcer are uneven, and granulation tissue is avoid standing or sitting for prolonged periods. The client evident. The skin has a brown pigmentation from accumulation should remain lying down unless performing a specific of metabolic waste products resulting from venous stasis. The activity for the first few days following the procedure. client also exhibits peripheral edema. Prolonged standing and sitting increase the risk of edema in the legs by decreasing blood return to the heart. The client The first signs and symptoms of digoxin toxicity in adults should avoid crossing the legs at any level for the same include abdominal pain, nausea, vomiting, visual disturbances reason. (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. The jaw thrust without the head tilt maneuver is used when head and/or neck trauma is suspected. This maneuver opens The magnetic fields used for magnetic resonance imaging the airway while maintaining proper head and neck (MRI) can deactivate the pacemaker alignment, thus reducing the risk of further damage to the neck. Option 1 is incorrect. In situations requiring CPR, the Variant angina, or Prinzmetals angina, is prolonged and severe client will be unconscious. Option 4 is also incorrect. and occurs at the same time each day, most often at rest. Additionally, it is unlikely that the nurse will be able to obtain Stable angina is induced by exercise and relieved by rest or these data. nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is Fruits and vegetables, except avocado, olives, and coconut, often a precursor of myocardial infarction. contain minimal amounts of fat. The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Aminocaproic acid is the antidote for thrombolytic therapy. Potassium chloride is administered for a potassium deficit. TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is a complication of TSS.

Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular The therapeutic range for prothrombin time is 1.5 to 2 times vein distention, and a falling blood pressure accompanied by the control for clients at high risk for thrombus. Based on the pulsus paradoxus (a drop in inspiratory BP greater than 10 clients control value, the therapeutic range for this individual mm Hg). Bradycardia is not a sign of cardiac tamponade. would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range.

Foot care instructions for the client with peripheral arterial disease are the same instructions as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program, such as Buerger-Allen exercises, or unless venous stasis is also present.

and the saphenous nerve run close together, and damage to the nerve will produce paresthesias.

A PASG may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing Captopril is an antihypertensive medication (angiotension- assessment includes monitoring the vascular status of the converting enzyme inhibitor). Orthostatic hypotension can lower extremities. occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods of time, to The normal LAP is 1 to 10 mm Hg. Because the left atrium change positions slowly, and to avoid extreme warmth such as does not generate significant pressure during atrial with baths, showers, or heat from the sun in warm weather. contraction, the atrial pressure is recorded as an average The client should be instructed to monitor for signs of (mean) pressure, rather than as a systolic or diastolic orthostatic hypotension such as dizziness, lightheadedness, pressure. weakness, and syncope. An increased intake of water could actually aggravate the hypertension. The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females. A critical value is one The sodium level can increase by the use of several types of that is less than 100 mg/dL. With DIC, the fibrinogen level products including toothpaste and mouthwash; over-the- drops because fibrinogen is used up in the clotting process. counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water, as well as some mineral Raynauds disease is peripheral vascular disease water. Clients are instructed to read labels for sodium content. characterized by abnormal vasoconstriction in the Water that is bottled, distilled, deionized, and demineralized extremities. Smoking cessation is one of the most important may be used for drinking and cooking. Fresh fruits and lifestyle changes that the client needs to make. The nurse vegetables are low in sodium. The client would avoid should emphasize the effects of tobacco on the blood consuming mineral water. vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about Arterial ulcers have a pale, deep base and are surrounded by smoking cessation programs available in the community tissue that is cool with trophic changes such as dry, skin and loss of hair. Arterial ulcers are caused by tissue ischemia from In the client with a venous disorder, the legs are elevated inadequate arterial supply of oxygen and nutrients. A venous above the level of the heart to assist with the return of stasis ulcer is one that has a dark red base and is surrounded venous blood to the heart. Option 2 specifies infrequent care by brown skin with local edema. This type of ulcer is caused intervals, so it is not the priority intervention. Alcohol is very by the accumulation of waste products of metabolism that are irritating and drying to tissues and should not be used in not cleared, as a result of venous congestion. A stage 1 ulcer areas of skin breakdown. indicates a reddened area with an intact skin surface. IABP therapy most often is used in the treatment of Standard management for the client with DVT includes bed cardiogenic shock and is most effective if instituted early in rest for 5 to 7 days, limb elevation, relief of discomfort with the course of treatment. Use of the IABP is contraindicated warm moist heat, and analgesics as needed. Ambulation is in clients with aortic insufficiency and thoracic and contraindicated because such activity can cause the thrombus abdominal aneurysms. This therapy is not used in the to dislodge and travel to the lungs. Opioid analgesics are not treatment of congestive heart failure or pulmonary edema. required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol). Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, Sclerotherapy is the injection of a sclerosing agent into a and assay for this protein is used in some institutions to aid varicosity. The agent damages the vessel and causes aseptic in the diagnosis of a myocardial infarction. thrombosis that results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical The client with heart failure may present with different procedure for varicose veins is vein ligation and stripping. This symptoms depending on whether the right or the left side of procedure involves tying off the varicose vein and large the heart is failing. Peripheral and sacral edema, jugular vein tributaries and then removal of the vein with the use of a hook distention, and organomegaly all are manifestations of and wires applied through multiple small incisions in the leg. problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function. A sensation of pins and needles, or feeling as though the surgical limb is falling asleep, may indicate temporary or Spironolactone is a potassium-sparing diuretic. Side effects permanent nerve damage after surgery. The saphenous vein include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is

hypokalemia, this medication is potassium sparing, which skeletal muscle. The WBC count would most likely be means that the concern with this medication is hyperkalemia. elevated in the client with an MI Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever. Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client with MI. Although The client should be instructed to take quinidine sulfate monitoring mental status is a component of the nurses exactly as prescribed. The client should not chew the assessment, it is not the priority after administration of sustained-release capsules or open the capsules and mix them morphine sulfate. The nurse would monitor the clients with food. The client should be instructed to wear a medical respirations and blood pressure. Signs of morphine toxicity identification bracelet or tag and to continue taking digoxin as include respiratory depression and hypotension. Urinary prescribed. Quinidine sulfate is administered for atrial flutter or output is unrelated to the administration of this medication. fibrillation only after the client has been digitalized. Monitoring the temperature also is not associated with the use of this medication. The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output. Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the clients behavior as boredom or as either understanding or not understanding the material provided at the teaching session. The recommended INR range for oral anticoagulant therapy is 2.0 to 3.0, but this value may vary with the goals of therapy. A recommended INR range with mechanical prosthetic heart valve is 2.5 to 3.5, and for survivors of acute myocardial infarction (MI), 2.5 to 3.5. The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client. Pressure should be applied to the site after an arterial blood gas specimen is drawn. The blood pressure in the artery is higher than in the veins, so applying pressure to the punctured artery is necessary to control bleeding. Covering the site with gauze may protect the site but would not control bleeding. Heat (by application of warm packs) causes vasodilation, which would increase bleeding to the site. Exercise would increase circulation to the area. The MM fraction of creatine kinase (CK-MB) is specific in determining the presence of MI. The CK-MM reflects injury to