Nokea
At 0745 hours, the nurse is informed by the HCP that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse’s priority?
- A. Place the client on NPO (nothing per mouth) status.
- B. Teach the client about the cardiac catheterization.
- C. Start an intravenous (IV) infusion of 0.9% NaCl.
- D. Witness the client’s signature on the consent form.
Correct Answer: A
Rationale: A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam, during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure, making this the priority at 0745 for a 1400 procedure.
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The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply.
- A. Increase isometric arm exercises to build endurance.
- B. Wear a facemask when outdoors in cold weather.
- C. Take nitroglycerin before a stressful event even if pain free.
- D. Perform most exertional activities in the morning.
- E. Take a daily laxative to avoid straining with bowel movements.
- F. Discontinue use of all tobacco products if you use these.
Correct Answer: B;C;F
Rationale: The nurse should instruct: B) Wearing a facemask in cold weather to prevent vasoconstriction; C) Taking nitroglycerin prophylactically to improve coronary blood flow; F) Discontinuing tobacco to reduce vasoconstriction. Isometric exercises, morning exertion, and daily laxatives are not recommended as they may increase cardiac workload or cause other issues.
The nurse is assessing the client following an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites?
- A. Left-sided heart failure
- B. Pulmonic valve malfunction
- C. Right-sided heart failure
- D. Ruptured septum
Correct Answer: C
Rationale: Right-sided HF produces venous congestion in the systemic circulation, resulting in JVD and ascites (from vascular congestion in the GI tract). Left-sided HF causes pulmonary congestion, pulmonic valve issues cause murmurs, and a ruptured septum causes shock and murmurs, none of which match the findings.
The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
- A. Jugular vein distention, muffled heart sounds, and BP 84/48
- B. Temperature 96.4°F (35.8°C), heart rate 58 bpm, and shivering
- C. Increased heart rate, audible S1 and S2, and pain rated at a 5
- D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few PVCs
Correct Answer: A
Rationale: The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse’s priority intervention?
- A. Palpate pedal pulses
- B. Measure vital signs
- C. Assess for urticaria
- D. Check the insertion site
Correct Answer: D
Rationale: Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases the risk for clot disruption and bleeding from the femoral artery. Pedal pulses, vital signs, and urticaria are secondary concerns.
The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client’s MAP is abnormal?
- A. 94/60 mm Hg
- B. 98/36 mm Hg
- C. 110/50 mm Hg
- D. 140/78 mm Hg
Correct Answer: B
Rationale: The Mean Arterial Pressure (MAP) is calculated as (SBP + 2*DBP)/3. For 98/36 mm Hg: (98 + 2*36)/3 = (98 + 72)/3 = 170/3 ≈ 56.67 mm Hg, which is abnormally low (normal MAP is 70-100 mm Hg), indicating potential hypoperfusion. Other readings yield: A: (94 + 2*60)/3 ≈ 71.33 mm Hg, C: (110 + 2*50)/3 ≈ 70 mm Hg, D: (140 + 2*78)/3 ≈ 98.67 mm Hg, all within or closer to normal range.