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The client presents to the Emergency Department with blunt trauma causing bruising and bleeding of the heart. The nurse knows that which of the following may help stop the bleeding?
- A. Embolectomy
- B. Pericardiocentesis
- C. Thoracentesis
- D. Inactivity and pressure from blood in the pericardium
Correct Answer: D
Rationale: The inactivity and increased pressure from blood in the pericardium may stop the bleeding. The client may need to have the blood aspirated from the pericardial sac, in which case pericardiocentesis is performed. One aspiration is sufficient in most cases, but if bleeding continues, open thoracotomy is indicated to control blood loss. Procedures to stop the bleeding caused by heart trauma do not include embolectomy or thoracentesis. Pericarditis is inflammation of the pericardium.
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The nurse is caring for an older adult client who is deciding whether to have cardiovascular surgery. The client asks the nurse why the risks are greater for them than for a younger person. What would be the nurse's answer?
- A. Many older adults have comorbidities in addition to their cardiac problems.
- B. Older adults have the same risk factors as younger adults.
- C. Older adults have hypersensitive renal systems, and younger adults don't.
- D. Older adults have different thought processes than younger adults do.
Correct Answer: A
Rationale: Many older adults have comorbidities such as diabetes, heart failure, cardiac dysrhythmias, hypertension, and poor renal function, necessitating careful consideration regarding the potential risks and benefits of cardiovascular surgery. These clients require close observation during the postoperative period. The other options are incorrect.
A client has been waiting for a donor heart for several months. Upon receiving the call that a heart has become available, the client asks the transplant nurse, 'How much time do I have to get to the hospital?' What answer should the nurse give the client?
- A. You can take your time. We have to get your heart so it could be 24 hours.
- B. You must be at the hospital within the next 15 minutes, or your heart will go the next person on the list.
- C. The heart has to be transplanted within 6 hours, so it is advisable that you go to the hospital to be prepared now.
- D. We can put the heart on ice and wait for you for 2 days.
Correct Answer: C
Rationale: When a donor heart becomes available, it must be removed from the donor and transplanted within 6 hours of being harvested. It is unreasonable to expect a client to be in the hospital within 15 minutes and would be an incorrect time frame.
After being discharged from the hospital after undergoing cardiothoracic surgery, the client asks the nurse when it will be possible to resume sexual activity. What is the best response by the nurse?
- A. I can't believe you are worried about that so soon after your surgery.
- B. You won't be able to resume sexual activity until your 6-month checkup with the surgeon.
- C. In about 2 to 4 weeks if you are able to climb stairs without difficulty breathing or chest pain.
- D. You may have a difficult time resuming sexual activities after this surgery.
Correct Answer: C
Rationale: Sexual relations usually can be resumed in 2 to 4 weeks after cardiothoracic surgery depending on one's comfort level and tolerance for activity; climbing two flights of stairs without dyspnea or chest pain is a common guideline. The other options are nontherapeutic responses to the client's concern. Six months is an excessively long time period to wait if the client has been able to resume activities without shortness of breath or chest pain.
The nurse is obtaining vital signs for a client in the clinic who has had a cardiac transplant. The nurse obtains an apical heart rate of 110 beats/minute. What is a priority action by the nurse?
- A. Obtain an electrocardiogram.
- B. Notify the physician.
- C. No action is required because the transplanted heart beats faster than the natural heart.
- D. Administer a calcium channel blocker to decrease the heart rate.
Correct Answer: C
Rationale: The transplanted heart beats faster than the client's natural heart, averaging about 100 to 110 beats/minute, because nerves that affect heart rate have been severed. The new heart also takes longer to increase the heart rate in response to exercise. If the client is asymptomatic, there is no reason to obtain an ECG or notify the physician. The nurse would not administer the calcium channel blocker without a physician's prescription.
A client is in the intensive care unit with a diagnosis of severe uncontrolled hypertension. What method of monitoring would best meet the needs of this client?
- A. Central venous pressure monitoring
- B. Direct blood pressure monitoring
- C. Pulmonary artery pressure monitoring
- D. Manual blood pressure readings with a sphygmomanometer
Correct Answer: B
Rationale: Direct blood pressure monitoring continuously displays the waveform and indicates the client's systolic, diastolic, and mean arterial pressures. This type of equipment eliminates the need to auscultate the BP. Direct BP monitoring may be used in clients with severe and sustained hypertension or hypotension and during and after cardiac surgery. Central venous pressure monitoring would be used to detect an excess or deficit in venous blood volume and would not be indicated for this client. Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances prevents left-sided heart failure or promotes its early correction and helps monitor the client's response to treatment and would not be indicated for this client. A manual reading is dependent on who takes the BP and can vary in its readings. It is not as accurate as the direct blood pressure monitoring.