Nokea
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.
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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 assessment finding best supports the assumption that the client is a good treatment.
- A. Pericardial friction rub
- B. Muffled heart sounds
- C. S3 gallop
- D. Systolic murmur
Correct Answer: A
Rationale: Pericardial friction rub is characteristic of pericarditis due to inflamed pericardial layers.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
The client is being evaluated for valvular heart disease. Which information would be most significant?
- A. The client has a history of coronary artery disease.
- B. There is a family history of valvular heart disease.
- C. The client has a history of smoking for 10 years.
- D. The client has a history of rheumatic heart disease.
Correct Answer: D
Rationale: Rheumatic heart disease (D) is a major cause of valvular disease, especially mitral/aortic. CAD (A), family history (B), and smoking (C) are less directly causative.
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.