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. The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

naturally lower in fat. Cream cheese is a high-fat food. When performing cardiopulmonary resuscitation (CPR) on an adult client, the sternum is depressed 1½ to 2 inches. 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 suddenly with severe dyspnea The normal therapeutic range for digoxin is 0.5 to 2.0 accompanying the chest pain. Dissecting aortic ng/mL. A level of 2.4 ng/mL exceeds the therapeutic aneurysms usually are accompanied by back pain. range and indicates toxicity. The most important action is to notify the physician, who may give further orders On transfer from the coronary care unit, the client is about holding further doses of digoxin. Option 3 is allowed self-care activities and bathroom privileges. incorrect because the level is not normal. The next Supervised ambulation in the hall for brief distances dose should not be administered because the serum is encouraged, with distances gradually increased digoxin level exceeds the therapeutic range. Checking (50, 100, 200 feet). the client’s last pulse rate is not incorrect but may have limited value in this situation. Depending on the Metformin (Glucophage) needs to be withheld 48 time that has elapsed since the last assessment, a hours before and after cardiac catheterization current assessment of the client’s status may be more because of the injection of contrast medium during useful. the procedure. If the contrast medium affects kidney function, with metformin in the system, the client The normal activated partial thromboplastin time would be at increased risk for lactic acidosis. (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The Hypotension and dizziness are signs of decreased therapeutic dose of heparin for treatment of deep vein cardiac output. Transcutaneous pacing provides a thrombosis is to keep the aPTT between 1.5 and 2.5 temporary measure to increase the heart rate and times normal. Thus, the client’s aPTT is within the thus perfusion in the symptomatic client. Digoxin will therapeutic range, and the dose should remain further decrease the client’s heart rate. Defibrillation unchanged. is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to The normal serum potassium level in the adult is 3.5 to monitor the client delays necessary intervention. 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a Edema, the accumulation of excess fluid in the client with a low potassium level and a history of interstitial spaces, can be measured by intake cardiac problems could precipitate ventricular greater than output and by a sudden increase in dysrhythmias. weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium Foods that are lower in sodium include fruits and restrictions are reserved for clients with severe vegetables (option 4), because they do not contain symptoms. physiological saline. Highly processed or refined foods (options 1 and 3) are higher in sodium unless their Heart failure is precipitated or exacerbated by food labels specifically state “low sodium.” Saltwater physical or emotional stress, dysrhythmias, fish and shellfish are high in sodium. infections, anemia, thyroid disorders, pregnancy, Fruits and vegetables tend to be lower in fat because Paget’s disease, nutritional deficiencies (thiamine, they do not come from animal sources. Fish is also alcoholism), pulmonary disease, and hypervolemia.

Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart.

Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, Pulmonary edema is characterized by extreme the atrial and ventricular rates are higher than 100 breathlessness, dyspnea, air hunger, and the beats/min. production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished Motion artifact, or “noise,” can be caused by frequent breath sounds are not associated with pulmonary client movement, electrode placement on limbs, and edema. Stridor is a crowing sound associated with insufficient adhesion to the skin, such as placing laryngospasm or edema of the upper airway. electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be Pulmonary edema causes the client to be extremely avoided. Signal interference also can occur with agitated and anxious. The client may complain of a electrode removal and cable disconnection. sense of drowning, suffocation, or smothering. Ventricular tachycardia is characterized by the The serum potassium level is measured in the client absence of P waves, wide QRS complexes (longer receiving digoxin and furosemide. Heightened digoxin than 0.12 second), and typically a rate between 140 effect leading to digoxin toxicity can occur in the client and 180 impulses/min. The rhythm is regular. with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic Classic signs of cardiogenic shock as they relate to this focus that takes over as the pacemaker for the heart. question include low blood pressure and tachycardia. The low cardiac output that results can lead quickly The central venous pressure would rise as the to cerebral and myocardial ischemia. Clients backward effects of the severe left ventricular failure frequently experience a feeling of impending doom. became apparent. Dysrhythmias commonly occur as a Ventricular tachycardia is treated with result of decreased oxygenation and severe damage to antidysrhythmic medications, cardioversion (client greater than 40% of the myocardium. awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into Sternotomy incision sites are assessed for signs and ventricular fibrillation at any time. symptoms of infection, such as redness, swelling, induration, and drainage. Elevated temperature and First-line treatment of ventricular tachycardia in a white blood cell count after 3 to 4 days postoperatively client who is hemodynamically stable is the use of usually indicate infection. antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). The client who undergoes cardiac surgery is at risk for Cardioversion also may be needed to correct the renal injury from poor perfusion, hemolysis, low cardiac rhythm (cardioversion is recommended for stable output, or vasopressor medication therapy. Renal insult ventricular tachycardia). Defibrillation is used with is signaled by decreased urine output and increased pulseless ventricular tachycardia. Epinephrine would blood urea nitrogen and creatinine levels. The client stimulate an already excitable ventricle and is may need medications to increase renal perfusion and contraindicated. possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of Cough cardiopulmonary resuscitation (CPR) hypovolemia, urinary tract infection, or sometimes is used in the client with unstable glomerulonephritis. ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and The nurse should encourage regular use of pain coughing forcefully every 1 to 3 seconds. Cough CPR medication for the first 48 to 72 hours after cardiac may terminate the dysrhythmia or sustain the surgery because analgesia will promote rest, decrease cerebral and coronary circulation for a short time myocardial oxygen consumption resulting from pain, until other measures can be implemented. and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 The client with uncontrolled atrial fibrillation with a and 4 will not help in tolerating ambulation. Removal of ventricular rate more than 100 beats/min is at risk telemetry equipment is contraindicated unless for low cardiac output because of loss of atrial kick. prescribed. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit,

fatigue, weakness, dizziness, syncope, shortness of who have survived sudden cardiac death unrelated breath, and distended neck veins. to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal Atrial fibrillation is characterized by a loss of P waves episodes related to ventricular tachycardia. and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation. In the first several hours after insertion of a permanent or a temporary pacemaker, the most Carotid sinus massage is one maneuver used for vagal common complication is pacing electrode stimulation to decrease a rapid heart rate and possibly dislodgement. The nurse helps prevent this terminate a tachydysrhythmia. The others include complication by limiting the client’s activities of the inducing the gag reflex and asking the client to strain arm on the side of the insertion site. or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the Pulmonary embolism is a life-threatening normal rhythm. complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common Ventricular fibrillation is characterized by irregular symptom, which is sudden in onset, and may be chaotic undulations of varying amplitudes. Ventricular aggravated by breathing. Other signs and symptoms fibrillation has no measurable rate and no visible P include dyspnea, cough, diaphoresis, and waves or QRS complexes and results from electrical apprehension. chaos in the ventricles. Sclerotherapy is the injection of a sclerosing agent Until the defibrillator is attached and charged, the into a varicosity. The agent damages the vessel and client is resuscitated by using cardiopulmonary causes aseptic thrombosis, which results in vein resuscitation. Once the defibrillator has been attached, closure. With no blood flow through the vessel, there the electrocardiogram is checked to verify that the is no distention. The surgical procedure for varicose rhythm is ventricular fibrillation or pulseless ventricular veins is vein ligation and stripping. This procedure tachycardia. Leads also are checked for any loose involves tying off the varicose vein and large connections. A nitroglycerin patch, if present, is tributaries and then removing the vein with hook and removed. The client does not have to be intubated to wires via multiple small incisions in the leg. be defibrillated. Lidocaine may be given subsequently but is not required before defibrillation. The machine is Hypersensitivity or a sensation of “pins and needles” not set to the synchronous mode because there is no in the surgical limb may indicate temporary or underlying rhythm with which to synchronize. permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close The client may be defibrillated up to three times in together in the distal third of the leg. Because succession. The energy levels used are 200, 300, and complications from this surgery are relatively rare, 360 J for the first, second, and third attempts, this symptom should be reported. respectively. The mixture of arterial and venous manifestations After defibrillation, the client requires continuous (claudication and phlebitis, respectively) in the young monitoring of electrocardiographic rhythm, male client suggests thromboangiitis obliterans hemodynamic status, and neurological status. (Buerger’s disease). This disorder is characterized by Respiratory and metabolic acidosis develops during inflammation and thrombosis of smaller arteries and ventricular fibrillation because of lack of respiration veins. It typically is found in young adult males who and cardiac output. These can cause cerebral and smoke. The cause is not known precisely but is cardiopulmonary complications. Arousable status, suspected to have an autoimmune component. adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation. Raynaud’s disease responds favorably to eliminating caffeine from the diet and cessation of smoking. The nurse or rescuer puts two large adhesive patch Medications may inhibit vessel spasm and prevent electrodes on the client’s chest in the usual symptoms. Avoiding exposure to cold through a defibrillator positions. The nurse stops variety of means is important. However, moving to a cardiopulmonary resuscitation and orders anyone near warmer climate may not necessarily be beneficial the client to move away and not touch the client. The because the symptoms still could occur with the use defibrillator then analyzes the rhythm, which may take of air conditioning and during periods of cooler up to 30 seconds. The machine then indicates if weather. defibrillation is necessary After inferior vena cava filter insertion, the nurse An automatic internal cardioverter-defibrillator (AICD) inspects the surgical site for bleeding and signs and detects and delivers an electrical shock to terminate symptoms of infection. Otherwise, care is the same life-threatening episodes of ventricular tachycardia and as for any other postoperative client. ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those

An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block. This test is an alternative to the exercise thallium-201 scan. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as should bronchodilators such as theophylline. Theophylline may decrease the effects of dipyridamole. 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 averaged.

halos around dysrhythmias.

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The magnetic fields used for magnetic resonance imaging (MRI) can deactivate the pacemaker Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. 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. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range.

Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The Warfarin sodium works in the liver and inhibits client usually expresses immediate relief. Heart sounds synthesis of four vitamin K-dependent clotting factors are no longer muffled or distant. (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the The antidote to warfarin sodium (Coumadin) is “heart beating” in the abdomen when supine or being vitamin K and should be readily available for use if able to feel the mass throbbing. A pulsatile mass may excessive bleeding or hemorrhage occurs. be palpated in the middle and upper abdomen. A Aminocaproic acid is the antidote for thrombolytic systolic bruit may be auscultated over the mass. agents. Protamine sulfate is the antidote for heparin. Hyperactive bowel sounds are not related specifically Potassium chloride is administered to treat potassium to an abdominal aortic aneurysm. deficit. Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of renal failure. Renal failure can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and notes the results of daily blood urea nitrogen and creatinine levels. Urine output lower than 30 to 50 mL/hr is reported to the physician. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the physician before initiating therapy. The ACLS nurse would place one gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads. Options 1, 3, and 4 identify incorrect positions.

The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless The first signs and symptoms of digoxin toxicity in performing a specific activity for the first few days adults include abdominal pain, nausea, vomiting, following the procedure. Prolonged standing and visual disturbances (blurred, yellow, or green vision, sitting increase the risk of edema in the legs by

decreasing blood return to the heart. The client should supply of oxygen and nutrients. A venous stasis ulcer avoid crossing the legs at any level for the same is one that has a dark red base and is surrounded by reason. brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of The jaw thrust without the head tilt maneuver is used metabolism that are not cleared, as a result of when head and/or neck trauma is suspected. This venous congestion. A stage 1 ulcer indicates a maneuver opens the airway while maintaining proper reddened area with an intact skin surface. head and neck alignment, thus reducing the risk of further damage to the neck. Option 1 is incorrect. In Standard management for the client with DVT situations requiring CPR, the client will be unconscious. includes bed rest for 5 to 7 days, limb elevation, Option 4 is also incorrect. Additionally, it is unlikely relief of discomfort with warm moist heat, and that the nurse will be able to obtain these data. analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to Fruits and vegetables, except avocado, olives, and dislodge and travel to the lungs. Opioid analgesics coconut, contain minimal amounts of fat. are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol). TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is Sclerotherapy is the injection of a sclerosing agent a complication of TSS. into a varicosity. The agent damages the vessel and causes aseptic thrombosis that results in vein Assessment findings associated with cardiac closure. With no blood flow through the vessel, tamponade include tachycardia, distant or muffled distention will not occur. The surgical procedure for heart sounds, jugular vein distention, and a falling varicose veins is vein ligation and stripping. This blood pressure accompanied by pulsus paradoxus (a procedure involves tying off the varicose vein and drop in inspiratory BP greater than 10 mm Hg). large tributaries and then removal of the vein with Bradycardia is not a sign of cardiac tamponade. the use of a hook and wires applied through multiple small incisions in the leg. Foot care instructions for the client with peripheral arterial disease are the same instructions as those for A sensation of pins and needles, or feeling as though a client with diabetes mellitus. The client with arterial the surgical limb is falling asleep, may indicate disease, however, should avoid raising the legs above temporary or permanent nerve damage after surgery. the level of the heart unless instructed to do so as part The saphenous vein and the saphenous nerve run of an exercise program, such as Buerger-Allen close together, and damage to the nerve will produce exercises, or unless venous stasis is also present. paresthesias. Captopril is an antihypertensive medication (angiotension-converting enzyme inhibitor). Orthostatic hypotension can occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods of time, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension such as dizziness, lightheadedness, weakness, and syncope. An increased intake of water could actually aggravate the hypertension. 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 assessment includes monitoring the vascular status of the lower extremities.

The normal LAP is 1 to 10 mm Hg. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic The sodium level can increase by the use of several or diastolic pressure. types of products including toothpaste and mouthwash; over-the-counter medications such as The normal fibrinogen level is 180 to 340 mg/dL for analgesics, antacids, laxatives, and sedatives; and males and 190 to 420 mg/dL for females. A critical softened water, as well as some mineral water. Clients value is one that is less than 100 mg/dL. With DIC, are instructed to read labels for sodium content. Water the fibrinogen level drops because fibrinogen is used that is bottled, distilled, deionized, and demineralized up in the clotting process. may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The client would avoid Raynaud’s disease is peripheral vascular disease consuming mineral water. characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most Arterial ulcers have a pale, deep base and are important lifestyle changes that the client needs to surrounded by tissue that is cool with trophic changes make. The nurse should emphasize the effects of such as dry, skin and loss of hair. Arterial ulcers are tobacco on the blood vessels and the principles caused by tissue ischemia from inadequate arterial involved in stopping smoking. The nurse needs to

provide information to the client about smoking discuss what has happened. Denial is a common cessation programs available in the community early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually In the client with a venous disorder, the legs are is manifested by symptoms of sympathetic nervous elevated above the level of the heart to assist with the system arousal. No data are provided in the question return of venous blood to the heart. Option 2 specifies that would lead the nurse to interpret the client’s infrequent care intervals, so it is not the priority behavior as boredom or as either understanding or intervention. Alcohol is very irritating and drying to not understanding the material provided at the tissues and should not be used in areas of skin teaching session. breakdown. The recommended INR range for oral anticoagulant IABP therapy most often is used in the treatment of therapy is 2.0 to 3.0, but this value may vary with cardiogenic shock and is most effective if instituted the goals of therapy. A recommended INR range with early in the course of treatment. Use of the IABP is mechanical prosthetic heart valve is 2.5 to 3.5, and contraindicated in clients with aortic insufficiency and for survivors of acute myocardial infarction (MI), 2.5 thoracic and abdominal aneurysms. This therapy is not to 3.5. used in the treatment of congestive heart failure or pulmonary edema. The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the Cardiac troponin T or cardiac troponin I has been found fifth intercostal space. A stethoscope should be to be a protein marker in the detection of myocardial placed in this area to pick up heart sounds most infarction, and assay for this protein is used in some clearly institutions to aid in the diagnosis of a myocardial infarction. The pain associated with angina results from ischemia of myocardial cells. The pain often is The client with heart failure may present with different precipitated by activity that places more oxygen symptoms depending on whether the right or the left demand on heart muscle. Supplemental oxygen will side of the heart is failing. Peripheral and sacral help to meet the added demands on the heart edema, jugular vein distention, and organomegaly all muscle. Oxygen does not dilate blood vessels or are manifestations of problems with right-sided heart prevent thrombus formation and does not directly function. Lung sounds constitute an accurate indicator calm the client. of left-sided heart function. Pressure should be applied to the site after an Spironolactone is a potassium-sparing diuretic. Side arterial blood gas specimen is drawn. The blood effects include hyperkalemia, dehydration, pressure in the artery is higher than in the veins, so hyponatremia, and lethargy. Although the concern with applying pressure to the punctured artery is most diuretics is hypokalemia, this medication is necessary to control bleeding. Covering the site with potassium sparing, which means that the concern with gauze may protect the site but would not control this medication is hyperkalemia. Additional side effects bleeding. Heat (by application of warm packs) causes include nausea, vomiting, cramping, diarrhea, vasodilation, which would increase bleeding to the headache, ataxia, drowsiness, confusion, and fever. site. Exercise would increase circulation to the area. The client should be instructed to take quinidine sulfate exactly as prescribed. The client should not chew the sustained-release capsules or open the capsules and mix them with food. The client should be instructed to wear a medical identification bracelet or tag and to continue taking digoxin as prescribed. Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized. 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 The MM fraction of creatine kinase (CK-MB) is specific in determining the presence of MI. The CK-MM reflects injury to skeletal muscle. The WBC count would most likely be elevated in the client with an MI Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client with MI. Although monitoring mental status is a component of the nurse’s assessment, it is not the priority after administration of morphine sulfate. The nurse would monitor the client’s respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature also is not associated with the use of this medication.