Nokea
A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?
- A. I should avoid taking a tub bath until my catheter site heals
- B. I should expect a low-grade fever and swelling at the site for the next week
- C. I should avoid prolonged sitting
- D. I should expect bruising at the catheter site for up to 3 weeks
Correct Answer: B
Rationale: Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.
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A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display?
- A. Fatty deposits in the lumen of arteries
- B. Cholesterol plugs in the lumen of veins
- C. Blood clots in the arteries
- D. Emboli in the veins
Correct Answer: A
Rationale: Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.
Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?
- A. Acute Pain
- B. Coping Impairment
- C. ADL Deficit
- D. Activity Intolerance
Correct Answer: A
Rationale: The hallmark symptom of Raynaud syndrome is acute pain related to the arterial insufficiency. ADL Deficit, Coping Impairment, and Activity Intolerance can occur but are less significant than Acute Pain.
After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?
- A. Troponin I
- B. Myoglobin
- C. WBC (white blood cell) count
- D. C-reactive protein
Correct Answer: B
Rationale: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels do not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?
- A. To dilate coronary arteries
- B. To decrease workload of the heart
- C. To decrease homocysteine levels
- D. To prevent angiotensin II conversion
Correct Answer: B
Rationale: Beta-adrenergic blockers are used in the treatment of CAD to decrease the consumption of myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
- A. Moderation is the key to everything
- B. Ask your physician to prescribe the new reverse lipid drug
- C. Increase the soy in your diet
- D. Exercise, keep your blood sugar in check, and manage your stress
Correct Answer: D
Rationale: Although moderation is the key, this does not provide specific options for this client such as regular exercise and managing stress and cholesterol levels. The reverse lipid drug sounds good but is not available or approved by the FDA. Soy products have limited benefits for cholesterol control.