Nokea
A client has been waiting for a donor heart for several months. Upon receiving the call that a heart has become available, the client asks the transplant nurse, 'How much time do I have to get to the hospital?' What answer should the nurse give the client?
- A. You can take your time. We have to get your heart so it could be 24 hours.
- B. You must be at the hospital within the next 15 minutes, or your heart will go the next person on the list.
- C. The heart has to be transplanted within 6 hours, so it is advisable that you go to the hospital to be prepared now.
- D. We can put the heart on ice and wait for you for 2 days.
Correct Answer: C
Rationale: When a donor heart becomes available, it must be removed from the donor and transplanted within 6 hours of being harvested. It is unreasonable to expect a client to be in the hospital within 15 minutes and would be an incorrect time frame.
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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.
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 has experienced a myocardial infarction (MI). After the acute stage of the MI, what is the most lethal complication the nurse should be aware can occur?
- A. Thrombophlebitis
- B. Ventricular aneurysm
- C. Mitral valve prolapse
- D. Septic shock
Correct Answer: B
Rationale: A ventricular aneurysm is the most lethal complication among clients who survive the acute stage of a myocardial infarction (MI). Thrombophlebitis is a complication of immobility. Mitral valve prolapse is an acquired disorder that is not a complication from having an MI. Cardiogenic shock, not septic shock, is a complication after sustaining an MI.
A client is at the clinic for follow-up after cardiothoracic surgery and tells the nurse, 'I don't know what is wrong with me. I don't want to eat, and I feel depressed.' What is the best response by the nurse to this statement?
- A. I think we need to get you in to see a psychiatrist.
- B. There should be no reason for you to be depressed. You came through the surgery fine.
- C. It may take several weeks for your appetite to return, and the depression is normal and temporary.
- D. You need to tell the physician because this could be serious.
Correct Answer: C
Rationale: Discharge instruction should be given prior to the client leaving the hospital about it taking several weeks for a normal appetite to return and that depression is normal and temporary. The client does not need psychiatric help at this point but may benefit from a support group with other clients that have had cardiothoracic surgery. Telling a client there is no reason for being depressed is nontherapeutic and demeans the client's feelings. Telling the client to inform the physician because the depression could be serious could cause alarm.
The nurse is preparing a client for coronary artery bypass surgery. What vessel does the nurse know is most commonly used for grafting?
- A. Saphenous vein
- B. Basilic vein
- C. Radial artery
- D. Gastroepiploic artery
Correct Answer: A
Rationale: The saphenous vein in the leg is the vessel most often used for grafting in coronary artery bypass. The basilic vein in the arm, radial artery in the arm, and gastroepiploic artery from the stomach are alternative graft vessels.