Nokea
A client has a pulmonary artery catheter for monitoring and to ensure fluid balance. When measuring pulmonary capillary wedge pressure, the nurse forgets to deflate the balloon and leaves it inflated. What outcome can be the result of this action by the nurse?
- A. Pulmonary embolism
- B. Pulmonary edema
- C. A myocardial infarction
- D. Pulmonary infarction
Correct Answer: D
Rationale: When measuring pulmonary capillary wedge pressure, the balloon must be deflated immediately after the pressure is measured to avoid pulmonary infarction from prolonged blockage of capillary blood flow. Pulmonary embolism, pulmonary edema, and myocardial infarction would not be the result of not deflating the balloon initially.
You may also like to solve these questions
A client has been admitted for a commissurotomy. The nurse knows that a commissurotomy repairs which of the following?
- A. A ventricle
- B. A valve
- C. Part of the myocardium
- D. An artery
Correct Answer: B
Rationale: Heart valves need surgical repair or replacement if they become narrowed (stenosed) or stretched (incompetent). One method of repair is commissurotomy (opening adhesions in the valve cusps), which is done without direct visualization of the valve.
A client was driving a car without wearing a seat belt and slid off the road and hit a tree. The client's chest was crushed against a steering wheel. What type of lethal injury does the nurse anticipate the client may have suffered?
- A. Cardiac tamponade
- B. A pleural effusion
- C. Bladder trauma
- D. Fractured pelvis
Correct Answer: A
Rationale: A nonpenetrating injury of the chest, such as being crushed against a steering wheel, may cause bruising and bleeding of the heart. Because the pericardium encloses the heart, blood accumulates in the pericardial space, resulting in cardiac tamponade. Although a fractured pelvis and bladder trauma may be sustained, they are generally not lethal. A pleural effusion would not result from this traumatic injury.
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.
The nurse is caring for an older adult client who is deciding whether to have cardiovascular surgery. The client asks the nurse why the risks are greater for them than for a younger person. What would be the nurse's answer?
- A. Many older adults have comorbidities in addition to their cardiac problems.
- B. Older adults have the same risk factors as younger adults.
- C. Older adults have hypersensitive renal systems, and younger adults don't.
- D. Older adults have different thought processes than younger adults do.
Correct Answer: A
Rationale: Many older adults have comorbidities such as diabetes, heart failure, cardiac dysrhythmias, hypertension, and poor renal function, necessitating careful consideration regarding the potential risks and benefits of cardiovascular surgery. These clients require close observation during the postoperative period. The other options are incorrect.
When discussing the nursing process, the instructor stresses that for clients undergoing cardiac surgery, it is important for the nurse to demonstrate competence. What is the rationale for this statement?
- A. To acknowledge the client's emotion
- B. To encourage verbal conversation
- C. To relieve the client's insecurity and anxiety
- D. To encourage the client to communicate
Correct Answer: C
Rationale: When the nurse is knowledgeable and competent, it relieves the client's insecurity and anxiety regarding the surgery.