Nokea
A client is in the intensive care unit with a diagnosis of severe uncontrolled hypertension. What method of monitoring would best meet the needs of this client?
- A. Central venous pressure monitoring
- B. Direct blood pressure monitoring
- C. Pulmonary artery pressure monitoring
- D. Manual blood pressure readings with a sphygmomanometer
Correct Answer: B
Rationale: Direct blood pressure monitoring continuously displays the waveform and indicates the client's systolic, diastolic, and mean arterial pressures. This type of equipment eliminates the need to auscultate the BP. Direct BP monitoring may be used in clients with severe and sustained hypertension or hypotension and during and after cardiac surgery. Central venous pressure monitoring would be used to detect an excess or deficit in venous blood volume and would not be indicated for this client. Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances prevents left-sided heart failure or promotes its early correction and helps monitor the client's response to treatment and would not be indicated for this client. A manual reading is dependent on who takes the BP and can vary in its readings. It is not as accurate as the direct blood pressure monitoring.
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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.
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 client will be having a surgical procedure that does not use cardiopulmonary bypass, and the surgeon keeps the heart at a rate of 40 beats/minute. What surgical procedure does the nurse anticipate preparing the client for?
- A. Port access coronary artery bypass (PACAB)
- B. Heart transplant
- C. Coronary artery bypass grafting
- D. Off-pump coronary artery bypass (OPCAB)
Correct Answer: D
Rationale: OPCAB is very similar to conventional CABG except that it does not involve the use of a cardiopulmonary bypass machine. Instead, the surgeon keeps the heart beating at a slow rate (about 40 beats/minute) with drugs such as adenosine and esmolol. The other answers require cardiopulmonary bypass.
A client recently had a myocardial infarction (MI) and asks the nurse if he will require a heart transplant. Based on the nurse's knowledge of indications for heart transplant, what is the best response?
- A. No. Heart transplant is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure.
- B. No. Heart transplant is only indicated for congenital heart defects.
- C. Yes. You may require a heart transplant if you have another heart attack.
- D. Yes. Your heart will not function as well as it did before the heart attack, and a new heart will give you the best chance for survival.
Correct Answer: A
Rationale: In adults, heart transplantation is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure. In newborns and infants, heart transplantation is indicated for a severe congenital cardiac defect. It is performed only when other treatment modalities fail or are unavailable. It is not used to treat clients after an MI unless they meet any of the given criteria.
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.