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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.
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The nurse is caring for a client who is having a mitral valve replacement with a mechanical valve. What instructions should the nurse be sure the client understands prior to being discharged?
- A. The valve should last for 10 to 15 years.
- B. The client will require anticoagulation.
- C. There is a low potential for thrombi formations so anticoagulation is not necessary.
- D. The valve is prone to calcification.
Correct Answer: B
Rationale: A mechanical valve should last at least 20 years. The disadvantages are the risk for thrombi and emboli, so anticoagulation is necessary. There is a risk of bleeding, and there can be a sudden malfunction in the valve. An allograft will last 10 to 15 years. A bioprosthetic valve does not require anticoagulation but is prone to deterioration and calcification.
The nurse is caring for a client who has had cardiothoracic surgery, and the nurse is palpating the peripheral pulses. The nurse cannot palpate the left lower extremity pulse. What is the first action by the nurse?
- A. Call the physician.
- B. Call the charge nurse.
- C. Apply a vasodilator such as nitroglycerin cream on the skin surface and then palpate.
- D. Use a Doppler ultrasound device.
Correct Answer: D
Rationale: Palpate the peripheral pulses or use a Doppler ultrasound device if the pulses are not palpable. Prior to calling the physician or notifying the charge nurse, attempt to use the Doppler, and then, if no pulse is heard, the nurse may notify either. Administration of medications without a physician's prescription is contraindicated.
The nursing instructor is giving a class on assessing cardiac clients after thoracic surgery. What assessment is most important for the nurse to perform when caring for this client?
- A. Pulmonary artery pressure
- B. Temperature
- C. Skin and mentation
- D. Blood pressure
Correct Answer: D
Rationale: The nurse assesses the blood pressure (BP) and pulse rate in both arms after thoracic surgery. Although it is necessary for the nurse to also assess pulmonary artery pressure, temperature, skin, and mentation after thoracic surgery, blood pressure and pulse rate are the most essential assessments.
A nurse caring for a client who has had cardiac surgery must understand how pulmonary artery pressure is monitored. What is important about pulmonary artery pressure?
- A. Aids in early treatment of right-sided congestive heart failure
- B. Aids in the early treatment of fluid imbalances
- C. Assesses right-sided heart pressures
- D. Assesses left atrial heart pressures
Correct Answer: B
Rationale: Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances, prevents left-sided congestive heart failure or promotes its early correction, and helps monitor the client's response to treatment. The other options are incorrect. The measurement of pulmonary artery pressure does not assess right-sided heart pressures or left atrial pressure.
A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following?
- A. Blood sugar level
- B. Fluid intake and urine output
- C. Mentation
- D. Arterial blood gases
Correct Answer: B
Rationale: While assessing a client undergoing cardiac or vascular surgery, the nurse assesses the client's fluid intake and urine output on an hourly basis. The nurse may assess the blood sugar level during the initial assessment process but not hourly. For a client undergoing a cardiac or vascular surgery, the nurse does not assess for mentation. Arterial blood gases would not be assessed hourly.