Nokea
A nurse prepares a client for coronary artery bypass graft surgery. The client states, 'I am afraid I might die.' How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low
- B. Would you like to speak with a chaplain prior to surgery?
- C. Tell me more about your concerns about the surgery
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: The nurse should explore the client's fears by encouraging open discussion, which helps address concerns and provide emotional support. Dismissing fears, redirecting to a chaplain, or focusing on support systems does not directly address the client's stated concern.
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A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse suspect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node, resulting in an increased heart rate. A heart rate of 120 beats/min is indicative of tachycardia, which is a compensatory mechanism for low blood pressure.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
- A. Thrombophlebitis
- B. Stroke
- C. Pulmonary embolism
- D. Myocardial infarction
- E. Cardiac tamponade
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
A nurse monitors a client 2 hours after a cardiac catheterization. Which findings would require immediate action? (Select all that apply.)
- A. Blood pressure of 142/88 mm Hg
- B. Serum potassium of 2.9 mEq/L
- C. Warmth and redness at the site
- D. Expanding hematoma
- E. Rhythm changes on the cardiac monitor
Correct Answer: B,D,E
Rationale: Hypokalemia (2.9 mEq/L), an expanding hematoma, and rhythm changes are serious complications requiring immediate action. Slightly elevated blood pressure and warmth/redness (if not severe) are less urgent in the immediate post-procedure period.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs
- B. I see lights flashing in front of my eyes
- C. I have trouble remembering things
- D. I wake up to urinate multiple times at night
Correct Answer: A
Rationale: Dyspnea on exertion, such as shortness of breath when climbing stairs, is an early manifestation of heart failure due to reduced cardiac output during activity. The other symptoms are not specific to heart failure.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching?
- A. The best way to lose weight is a high-protein, low-carbohydrate diet
- B. Follow the American Heart Association guidelines for nutrition
- C. A nutritionist will provide you with information about your new diet
- D. If you exercise more frequently, you won't need to change your diet
Correct Answer: B
Rationale: Clients at high risk for coronary artery disease should follow the American Heart Association guidelines, which emphasize a balanced diet low in saturated fats and high in fruits, vegetables, and whole grains to reduce cardiovascular risk.