Nokea
The client is scheduled for a coronary artery bypass graft in one week. Which instructions should the nurse provide to the client? Select all that apply.
- A. Stop taking aspirin now and any products containing aspirin.
- B. Do perform aerobic exercises 30 minutes daily before surgery.
- C. Use the prescribed antimicrobial soap before hospital arrival.
- D. Shave your chest and legs and then shower to remove the hair.
- E. Resume normal activities when discharged from the hospital.
Correct Answer: A;C
Rationale: The nurse should instruct: A) Stop aspirin to reduce bleeding risk; C) Use antimicrobial soap to decrease infection risk. Aerobic exercises (B) may be too strenuous, shaving (D) is done just before surgery, and normal activities (E) are restricted post-surgery.
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The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?
- A. Restart heparin therapy as soon as possible.
- B. Reinforce the abdominal incision dressing.
- C. Inspect the groin insertion site for bleeding.
- D. Increase fluids to promote excretion of the dye.
Correct Answer: C
Rationale: The procedure for placement of a vena cava filter is done percutaneously, usually through the subclavian or femoral vein approach. The nurse should check the groin insertion site for bleeding. Heparin is unnecessary, there’s no abdominal incision, and dye is not used.
The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?
- A. Draw blood for cardiac enzymes STAT
- B. Call the cardiac catheterization laboratory
- C. Apply 1 inch of nitroglycerin paste topically
- D. Apply 4 liters of oxygen via nasal cannula
Correct Answer: D
Rationale: The nurse’s priority intervention should be to increase oxygen to the heart muscle. Applying 4 liters of oxygen via nasal cannula addresses the immediate need to improve myocardial oxygenation in an evolving MI indicated by ST elevation. Cardiac enzymes, catheterization, and nitroglycerin are secondary actions.
The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.
The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?
- A. Administering antihypertensive medications
- B. Palpating the abdomen to determine the aneurysm’s size
- C. Inserting a nasogastric tube set to moderate suction
- D. Teaching about a diet high in potassium and low in sodium
Correct Answer: A
Rationale: The nurse should include administering antihypertensive medications to the client with a thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm rupture. Palpation is contraindicated, and NG tubes or specific diets are not indicated.
The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?
- A. Diuretics
- B. A low-sodium diet
- C. Home oxygen therapy
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: C
Rationale: In class II HF, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain, but symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics, low-sodium diet, and ACE inhibitors are standard treatments.