Nokea
After the coronary artery bypass graft (CABG) surgery, which assessment finding provides the best evidence that collateral circulation at the donor graft site is adequate?
- A. The client is free from chest pain.
- B. The client's heart rate remains regular.
- C. The client moves the operative leg easily.
- D. The client's heart rate remains regular.
Correct Answer: C
Rationale: Easy movement of the operative leg indicates adequate blood flow to the donor site, suggesting good collateral circulation.
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The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching?
- A. I must take all the prescribed antibiotics.'
- B. I may get a vaginal yeast infection with penicillin.'
- C. I will have no problems as long as I take my medication.'
- D. My throat culture was positive for a streptococcal infection.'
Correct Answer: C
Rationale: Assuming no problems with medication (C) ignores potential complications like recurrence, indicating a need for teaching. Completing antibiotics (A), yeast infection (B), and strep culture (D) are correct.
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
Because the client is exhibiting signs and symptoms of congestive heart failure (CHF), which position suggested by the nurse is most beneficial for the client at this time?
- A. Supine with knees slightly bent
- B. Side-lying on the right side
- C. Side-lying on the left side
- D. Semi-Fowler's position
Correct Answer: D
Rationale: Semi-Fowler's position (30-45 degrees) reduces preload and eases breathing in CHF.
An older adult is scheduled for coronary arteriography during a cardiac catheterization. Which nursing intervention will be essential as she recovers from the diagnostic procedure on the hospital unit?
- A. Encouraging frequent ambulation to prevent deep vein thrombosis
- B. Limiting fluid intake to prevent fluid overload
- C. Limiting dietary fiber to prevent diarrhea
- D. Assessing the arterial puncture site when taking vital signs
Correct Answer: D
Rationale: Assessing the arterial puncture site is essential to detect complications like bleeding or hematoma post-coronary arteriography.
Which prothrombin time value would be considered normal for a client who is receiving warfarin (Coumadin)?
- A. 12 seconds
- B. 20 seconds
- C. 60 seconds
- D. 98 seconds
Correct Answer: B
Rationale: For a client receiving warfarin, the prothrombin time should be 1.5 to 2 times the normal value (11 to 12.5 seconds). Twenty seconds falls within this therapeutic range. Twelve seconds is normal for someone not on warfarin. Sixty seconds is normal for a partial thromboplastin time (PTT) test, and 98 seconds would be therapeutic for heparin, not warfarin.