Nokea
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
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The client with Raynaud’s disease is seen in a vascular clinic 6 weeks after nifedipine has been prescribed. The nurse evaluates that the medication has been effective when which findings are noted?
- A. The client’s blood pressure is 110/68 mm Hg.
- B. The client states experiencing less pain and numbness.
- C. The client states that tolerance to heat is improved.
- D. The client walks without intermittent claudication
Correct Answer: B
Rationale: Raynaud’s disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm that result in pain and numbness. Nifedipine (Procardia), a calcium-channel blocker, causes vasodilation, thus reducing pain and numbness. BP changes, heat tolerance, and claudication are not primary indicators.
The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
- A. Oliguria
- B. Dyspnea
- C. Hypotension
- D. Abdominal distention
- E. Severe chest pain radiating to the back
Correct Answer: A;B;C;E
Rationale: A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.
The nurse is caring for the client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse?
- A. Copious chest tube output; now none for 1 hour
- B. Current core temperature of 101.3°F (38.5°C)
- C. pH 7.32; Paco2 48; HCO3 28; Pao2 80
- D. Urine output 160 mL in the last 4 hours
Correct Answer: A
Rationale: A copiously draining chest tube that is no longer draining indicates an obstruction. It should be most concerning because there is an increased risk for cardiac tamponade or pleural effusion. Slight fever, compensated respiratory acidosis, and adequate urine output are less urgent.
The client is admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.