Nokea
The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.
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The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.
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.
After the client has been successfully resuscitated by the nurse, which body position is most correct while awaiting transfer to the emergency department?
- A. Supine with the head elevated
- B. On the side upper knee flexed
- C. Prone with the head lowered
- D. Flat with the knees extended
Correct Answer: D
Rationale: Flat with knees extended ensures airway patency and circulation stability post-resuscitation.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.
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.