Nokea
A client had a cardiac transplant 6 weeks ago. The client calls the clinic and informs the nurse he has a fever of $101^{\circ} \mathrm{F}$, chest tenderness, and flulike symptoms. What does the nurse suspect the client is experiencing?
- A. Hyperacute rejection
- B. Acute rejection
- C. Chronic rejection
- D. Subacute rejection
Correct Answer: B
Rationale: Acute rejection occurs from 1 week to 3 months after the transplant; almost all transplant recipients experience acute rejection to some degree. Hyperacute rejection is rare and occurs within a few minutes of the transplant when the donor organ and recipient are extremely mismatched. Chronic rejection may occur at any time over the remaining lifetime of a recipient, causing varying degrees of damage to the donor heart. Subacute rejection is not a classification of rejection.
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The nurse is measuring central venous pressure readings for a client receiving fluid resuscitation. Prior to obtaining the reading, what nursing action is required?
- A. Have the head of the bed at $90^{\circ}$.
- B. Ensure the level of the transducer is at the level of the right atrium.
- C. Ensure the transducer is above the level of the heart.
- D. Ensure the transducer is 2 inches below the level of the heart.
Correct Answer: B
Rationale: When measuring CVP, the nurse makes sure that the transducer is at the level of the client's right atrium; otherwise, an incorrect reading is obtained. The client is positioned supine or with the head slightly elevated but in exactly the same position as during previous measurements. Between CVP measurements, the head of the bed can be raised or lowered.
The nurse listens to the lung sounds of a postoperative client and determines that the client is not able to clear the secretions from the lungs. What intervention should the nurse provide prior to suctioning?
- A. Hyperoxygenate the client with $100% oxygen.
- B. Place the client in the supine position.
- C. Plan to suction for at least 20 seconds to remove secretions.
- D. Administer a sedative prior to suctioning.
Correct Answer: A
Rationale: Hyperoxygenate with $100% oxygen before suctioning; do not suction for more than 10 to 15 seconds. Suctioning removes oxygen and can cause hypoxemia, myocardial ischemia, and dysrhythmias. Hyperoxygenation saturates the blood and hemoglobin to compensate for temporary removal during suctioning. Elevate the head of the bed; don't place the client in the supine position. Administering a sedative may cause respiratory depression and should be avoided prior to suctioning so the cough reflex will not be depressed.
The nurse is obtaining vital signs for a client in the clinic who has had a cardiac transplant. The nurse obtains an apical heart rate of 110 beats/minute. What is a priority action by the nurse?
- A. Obtain an electrocardiogram.
- B. Notify the physician.
- C. No action is required because the transplanted heart beats faster than the natural heart.
- D. Administer a calcium channel blocker to decrease the heart rate.
Correct Answer: C
Rationale: The transplanted heart beats faster than the client's natural heart, averaging about 100 to 110 beats/minute, because nerves that affect heart rate have been severed. The new heart also takes longer to increase the heart rate in response to exercise. If the client is asymptomatic, there is no reason to obtain an ECG or notify the physician. The nurse would not administer the calcium channel blocker without a physician's prescription.
A client is diagnosed with obstructive atherosclerotic plaque of the left carotid artery. What procedure does the nurse anticipate preparing the client for?
- A. Endarterectomy
- B. Thrombectomy
- C. Embolectomy
- D. Coronary artery bypass graft
Correct Answer: A
Rationale: Endarterectomy is the resection and removal of the lining of an artery. This type of surgery is performed to remove obstructive atherosclerotic plaques from the aorta, carotid, femoral, or popliteal arteries. A thrombectomy is used to remove a thrombus for a vessel. An embolectomy is the removal of an embolus. Coronary artery bypass grafting is not indicated for the removal of an atherosclerotic plaque.
The nurse is caring for a client postoperatively after undergoing a coronary artery bypass graft. What intervention can the nurse provide to reduce the risk of the development of wound dehiscence?
- A. Encourage oral fluids.
- B. Assess lung sounds every 8 hours.
- C. Suction the client every 2 hours.
- D. Assist the client to splint with a pillow when coughing and deep breathing.
Correct Answer: D
Rationale: Instruct the client to press a pillow against the chest when deep breathing, coughing, and performing active exercise. Splinting promotes comfort and decreases the potential for dehiscence. Encouraging oral fluids will not prevent dehiscence. Lungs should be assessed every 4 hours or more frequently according to the client's condition. Suction should only be provided as needed.