Nokea
The nurse is answering questions that the client and family have about the upcoming cardiovascular surgery the client is having. What expected outcome would be best for a nursing diagnosis of Knowledge Deficiency related to unfamiliarity with diagnostic tests, preoperative preparations, and postoperative care?
- A. Client and family will understand the purpose, preparation, and aftercare of tests and surgery.
- B. Provide verbal and written information concerning the surgical procedure and aftercare.
- C. Ask the client or family member to explain the surgical procedure before signing the consent form.
- D. Clarify misconceptions concerning surgery.
Correct Answer: A
Rationale: Client and family will understand the purpose, preparation, and aftercare of tests and surgery is an outcome statement that would be appropriate for the diagnostic statement. The other statements are all interventions that are associated with the diagnostic statement.
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A client was driving a car without wearing a seat belt and slid off the road and hit a tree. The client's chest was crushed against a steering wheel. What type of lethal injury does the nurse anticipate the client may have suffered?
- A. Cardiac tamponade
- B. A pleural effusion
- C. Bladder trauma
- D. Fractured pelvis
Correct Answer: A
Rationale: A nonpenetrating injury of the chest, such as being crushed against a steering wheel, may cause bruising and bleeding of the heart. Because the pericardium encloses the heart, blood accumulates in the pericardial space, resulting in cardiac tamponade. Although a fractured pelvis and bladder trauma may be sustained, they are generally not lethal. A pleural effusion would not result from this traumatic injury.
A client has just had cardiothoracic surgery and tells the nurse about having a 6-month-old grandchild. The client states, 'I can't wait to hold my grandchild!' What is the best response by the nurse?
- A. I bet your grandchild is wonderful, and I know you are glad you made it through the surgery.
- B. I am sure you are excited to see your grandchild, but you must refrain from lifting, pushing, or pulling anything over 10 pounds for at least 6 to 12 weeks.
- C. You will not be able to lift that grandchild for at least 6 months, but you can sit with him and play.
- D. You have done so well after your surgery, and there are no restrictions for your activities.
Correct Answer: B
Rationale: The client must refrain from lifting, pushing, or pulling anything that weighs more than 10 lb. until the physician relieves the restriction in approximately 6 to 12 weeks. Telling the client 'I know you are glad you made it through the surgery' is not an informative or therapeutic response. Six months for lifting is an excessive time frame for activity to resume. There are several restrictions that the client should be made aware of during the postoperative time period.
The client is being prepared for cardiothoracic surgery and is very apprehensive. What medication can be administered with a physician's prescription to decrease the amount of anesthetic that the client will receive in surgery?
- A. An antipsychotic drug
- B. An anxiolytic drug
- C. An anticholinergic drug
- D. An analgesic
Correct Answer: B
Rationale: Anxiolytics may be used before surgery to lessen anxiety and sedate the client. Clients who are relaxed and sedated when anesthesia is given require a smaller dose of anesthetic. An antipsychotic would not be indicated for this client. An anticholinergic medication may be given to decrease the amount of secretions the client will have during surgery but will not decrease anxiety. An analgesic is normally given postoperatively for pain control.
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.
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.