Nokea
The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client’s baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?
- A. BP 154/78 mm Hg
- B. Pedal pulses palpable at +1
- C. Left groin soft to palpation with 1 cm ecchymotic area
- D. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
Correct Answer: D
Rationale: An apical pulse of 132 bpm with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. Slight BP elevation, +1 pulses, and minor ecchymosis are less concerning without additional context.
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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 client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.
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 with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.” Which is the nurse’s best response?
- A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.”
- B. “Tell me if these are related to your having vivid nightmares?”
- C. “You may be experiencing this from an increased sodium intake in your diet.”
- D. “Tell me more about how often this is occurring and how you deal with it.”
Correct Answer: D
Rationale: When the client with HF expresses concerns about breathing, the nurse should further explore the comment with an open-ended statement because more information may be gained about how the client could diminish or handle the occurrence. Naming the condition (A), assuming nightmares (B), or sodium intake (C) does not facilitate further assessment.