The nurse checking the client's leg incision is aware that which is the most common blood vessel used in CABG surgery?
- A. The saphenous vein
- B. The femoral artery
- C. The popliteal vein
- D. The iliac artery
Correct Answer: A
Rationale: The saphenous vein is commonly used in CABG due to its accessibility and suitability for grafting.
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Having heard the observer's comment, which statement by the nurse would be most helpful for an untrained individual to remember if a trained individual is not present?
- A. An untrained person can always stay with the victim until help arrives.
- B. Do not worry about compressions; just breathe regularly in the mouth.
- C. Begin chest compressions in the center of the chest pressing down 2 inches (5 cm).
- D. Place the client flat and elevate the feet to promote circulation.
Correct Answer: C
Rationale: Untrained individuals can perform compression-only CPR, pressing 2 inches deep at 100-120 per minute.
When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.
A low-sodium, low-cholesterol, weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
- A. Baked skinless chicken and mashed potatoes
- B. Stir-fried Chinese vegetables and rice
- C. Tuna fish salad with celery sticks
- D. Grilled lean steak Ascertainly grilled lean steak with carrots
Correct Answer: A
Rationale: Baked skinless chicken and mashed potatoes are low in sodium and cholesterol, making them suitable for a heart-healthy diet. Stir-fried vegetables may contain high sodium sauces, tuna salad may include high-sodium dressings, and grilled steak is higher in cholesterol.
If the chest pain is not relieved after taking one nitroglycerin tablet, the nurse should teach the client to take what action?
- A. Take another tablet in 5 minutes.
- B. The nurse is the energy department.
- C. Call the physician immediately.
- D. Swallow two additional tablets.
Correct Answer: A
Rationale: If angina persists after one nitroglycerin tablet, another can be taken every 5 minutes up to three doses, then seek medical help if unrelieved.
During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
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