Nokea
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.
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The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.
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.
Which nursing diagnosis would be priority for the client diagnosed with myocarditis?
- A. Anxiety related to possible long-term complications.
- B. High risk for injury related to antibiotic therapy.
- C. Increased cardiac output related to valve regurgitation.
- D. Activity intolerance related to impaired cardiac muscle function.
Correct Answer: D
Rationale: Myocarditis impairs cardiac function, making activity intolerance (D) the priority due to reduced cardiac output. Anxiety (A), injury (B), and increased output (C) are less immediate or incorrect.
The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.
The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client?
- A. Prepare for a pericardiocentesis.
- B. Request STAT cardiac enzymes.
- C. Perform a 12-lead electrocardiogram.
- D. Assess the client's heart and lung sounds.
Correct Answer: A
Rationale: Cardiac tamponade requires pericardiocentesis (A) to remove fluid. Enzymes (B), ECG (C), and heart/lung sounds (D) are supportive but not primary.