Nokea
After the femoral artery has been cannulated and the client is returned to the room, what should the nurse plan to do first?
- A. Palpate the client's distal peripheral pulses10 pulses.
- B. Auscultate the client's heart and breath sounds.
- C. Percuss all four quadrants of the client's abdomen.
- D. Inspect the skin integrity in the client's groin.
Correct Answer: A
Rationale: Palpating distal pulses first ensures adequate circulation post-catheterization, detecting complications like arterial occlusion.
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Before the cardiac catheterization and coronary arteriogram, it is essential for the nurse will be taken about any allergy to iodine or which other substance?
- A. Penicillin
- B. Morphine
- C. Shellfish
- D. Eggs
Correct Answer: C
Rationale: Shellfish allergies often indicate a risk of iodine sensitivity, which is critical since contrast dye used in arteriograms contains iodine.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
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.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.