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A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients 02 saturation to be low. What action by the nurse is most appropriate?
- A. Return the client to bed and apply oxygen.
- B. Continue to monitor the client's oxygen saturation.
- C. Notify the healthcare provider immediately.
- D. Encourage the client to take deep breaths.
Correct Answer: A
Rationale: Low oxygen saturation in a client post-myocardial infarction indicates potential hypoxemia, which can worsen cardiac ischemia. The nurse should return the client to bed and apply oxygen to improve oxygenation. Monitoring should continue, but immediate action is needed. Notifying the provider may be necessary if the situation does not improve, but oxygen administration is the priority. Encouraging deep breaths may help but is not sufficient alone.
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The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. What action by the nurse is most appropriate?
- A. Continue to educate the client on possible healthy changes.
- B. Emphasize complications that can occur with noncompliance.
- C. Tell the client that denial is normal and will soon go away.
- D. You need to make sure the client understands this illness.
Correct Answer: A
Rationale: Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. The student should not disconcert this type of dental and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to understand the illness may not be effective.
Which are modifiable risk factors for coronary artery disease? (Select all that apply.)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
- E. Stress
Correct Answer: B,C,D,E
Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
A nurse is teaching about a positive inotrope to a client and their spouse. Which statement by the nurse is most appropriate to explain the action of these drugs to the client and spouse?
- A. It constrsits vessels, improving blood flow.
- B. It dilates vessels, which leaves the work of the heart.
- C. It increases the force of the hearts contractions.
- D. It slows the heart rate down for better filling.
Correct Answer: C
Rationale: A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
- A. Allow the client to rest quality.
- B. Assess the client for bleeding.
- C. Document the findings in the chart.
- D. Medicate the client for pain.
Correct Answer: B
Rationale: A major complication related to intra-arterial blood pressure monitoring is hemorrhages from the insertion site. Since the vital signs are out of the normal range, are a chance, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest, the nurse first needs to assess for bleeding.