Nokea
The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?
- A. “The ICD will give me a shock if my heart goes into ventricular fibrillation again.”
- B. “When I feel the first shock, my family should start CPR immediately and call 911.”
- C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
- D. “Some states do not allow driving until there is a 6-month discharge-free period.”
Correct Answer: B
Rationale: CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if there is more than one shock. This statement indicates further teaching is needed. The other statements are correct regarding ICD function, shock sensation, and driving restrictions.
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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.
The male client states to the nurse, “I’ve recovered after having my new artificial heart valve inserted. Now I want to have a vasectomy so I don’t get my wife pregnant.” What is the nurse’s best response?
- A. “That’s probably not a good idea. You could get an infection and damage the new valve.”
- B. “You seem relieved that surgery was successful and that you can enjoy a normal life again.”
- C. “Be sure to take a nitroglycerin tablet before sexual intercourse to prevent any chest pain.”
- D. “Inform your surgeon about the new valve so antibiotics are prescribed before the procedure.”
Correct Answer: D
Rationale: The surgeon should be aware of the artificial heart valve because antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The client is also taking an anticoagulant and would be at risk for bleeding. Other responses are incorrect or irrelevant.
The nurse completes discharge teaching for the client with chronic stage 2 hypertension. Which statement by the client indicates that teaching was effective?
- A. “I will limit my intake of potassium by eating bananas only once a week.”
- B. “I will start a rigorous exercise program to lose this excess weight.”
- C. “I will call my doctor immediately if I have sudden vision changes.”
- D. “I will strive to maintain my body mass index (BMI) at 32.”
Correct Answer: C
Rationale: Teaching is effective if the client states to call the HCP immediately if experiencing vision changes. Sudden vision changes may be associated with stroke, a complication of hypertension. Limiting potassium is unnecessary unless hyperkalemia is present, rigorous exercise should be gradual, and a BMI of 32 is obese, which is a risk factor for hypertension.
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 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.