Nokea
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
- A. Client on a nitroglycerin infusion at 5 mcg/min, not titired in the last 4 hours.
- B. Client who is 1 day post coronary artery bypass graft with blood pressure 100/60 mm Hg.
- C. Client with a heart rate of 100 beats/min after angioplasty.
- D. Client with tongue swelling and anxiety post-angioplasty.
Correct Answer: D
Rationale: The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 100 beats/min has increased oxygen demands but is just over the normal limit for heart rate. The two post-coronary artery bypass clients are stable.
You may also like to solve these questions
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
- A. Assess the clients papillary responses.
- B. Request an neurologic consultation.
- C. Stop the infusion and call the provider.
- D. Take and document a full set of vital signs.
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is an an intravenous infusion. The nurse is a client to respond, and now the client needs this medication. What response is the nurse is best.
- A. The t-PA didid dissolve the entire coronary clot.
- B. The heparin keeps that artery from getting blocked gain.
- C. The heparin keeps that artery from getting blocked gain.
- D. The heparin prevents a stroke from occurring as the t-PA wears off.
Correct Answer: B
Rationale: After the original intracanoary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoulding. The other statements are not accurate. Heparin is not a blood thinner, although neurologist may refer is a not.
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.
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.
A nurse is a caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP?) (Select all that apply.)
- A. Assist the client to the chair for meals and to the bathroom.
- B. Teach the client how to use the incentive spirometer.
- C. Ensure the client wears TED hose or sequential compression devices.
- D. Have the client rate pain on a 0-to-10 scale and report to the nurse.
- E. Take and record a full set of vital signs per hospital protocol.
Correct Answer: A,C,E
Rationale: The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs. The incentive spirometer should be used every hour the day after surgery, but teaching is a nursing responsibility. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse for a more detailed assessment.