Nokea
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?
- A. The client's BP is 110/70 and pulse is 90.
- B. The client's groin dressing is dry and intact.
- C. The client refuses to keep the leg straight.
- D. The client denies any numbness and tingling.
Correct Answer: C
Rationale: Refusing to keep the leg straight (C) risks bleeding from the femoral site, requiring immediate intervention. Normal BP/pulse (A), intact dressing (B), and no numbness (D) are expected.
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Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.
- A. Paroxysmal nocturnal dyspnea.
- B. Orthopnea.
- C. Cough.
- D. Pericardial friction rub.
- E. Pulsus paradoxus.
Correct Answer: A,B,C
Rationale: Valvular disease causes fluid overload, leading to PND (A), orthopnea (B), and cough (C). Pericardial rub (D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?
- A. Medicate the client with intravenous morphine.
- B. Assess the client's chest dressing and vital signs.
- C. Encourage the client to turn from side to side.
- D. Check the client's telemetry monitor.
Correct Answer: B
Rationale: Chest pain post-CABG may indicate complications. Assessing the dressing and vital signs (B) identifies bleeding or instability. Morphine (A), repositioning (C), and telemetry (D) follow.
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
- A. Bilateral peripheral pulses 2+.
- B. The pulse oximeter reading is 96%.
- C. The urine output is 240 mL in the last four (4) hours.
- D. Cool, clammy, diaphoretic skin.
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (A), SpO2 (B), and urine output (C) are normal.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client?
- A. Do not lift or carry more than 23 kg.
- B. Have someone drive the car for the rest of your life.
- C. Carry the cell phone on the opposite side of the ICD.
- D. Avoid using the microwave oven in the home.
Correct Answer: C
Rationale: Carrying the cell phone on the opposite side (C) minimizes electromagnetic interference with the ICD. Lifting limits (A) are typically 10–15 lbs initially, driving (B) is restricted temporarily, and microwaves (D) are safe.