Nokea
The nurse is assessing the client following an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites?
- A. Left-sided heart failure
- B. Pulmonic valve malfunction
- C. Right-sided heart failure
- D. Ruptured septum
Correct Answer: C
Rationale: Right-sided HF produces venous congestion in the systemic circulation, resulting in JVD and ascites (from vascular congestion in the GI tract). Left-sided HF causes pulmonary congestion, pulmonic valve issues cause murmurs, and a ruptured septum causes shock and murmurs, none of which match the findings.
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The client is discovered to have a popliteal aneurysm. Because of the aneurysm, the nurse should closely monitor the client for which associated problem?
- A. Thoracic outlet syndrome
- B. Ischemia in the lower limb
- C. Pulmonary embolism
- D. Raynaud’s phenomenon
Correct Answer: B
Rationale: A popliteal aneurysm (located in the space behind the knee) may cause ischemia in the leg distal to the aneurysm due to thrombus forming inside the aneurysm and potential emboli. Other options are unrelated to popliteal aneurysms.
After receiving normal CXR results of the client who had cardiac surgery, the nurse proceeds to remove the client’s chest tubes as prescribed. Which intervention should be the nurse’s priority?
- A. Auscultate the client’s lung sounds
- B. Administer 2 mg morphine sulfate intravenously
- C. Turn off the suction to the chest drainage system
- D. Prepare the dressing supplies at the client’s bedside
Correct Answer: B
Rationale: Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first to manage pain during chest tube removal. Auscultation, turning off suction, and preparing supplies are secondary.
The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
- A. Jugular vein distention, muffled heart sounds, and BP 84/48
- B. Temperature 96.4°F (35.8°C), heart rate 58 bpm, and shivering
- C. Increased heart rate, audible S1 and S2, and pain rated at a 5
- D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few PVCs
Correct Answer: A
Rationale: The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.
The nurse is caring for the client who had a cardiac valve replacement. To decrease the risk of DVT and PE, which interventions should the nurse plan to include? Select all that apply.
- A. Apply a pneumatic compression device.
- B. Administer a heparin infusion intravenously.
- C. Encourage coughing and deep breathing hourly.
- D. Teach about performing isometric leg exercises.
- E. Avoid the use of graded compression elastic stockings.
Correct Answer: A;D
Rationale: The nurse should include: A) Pneumatic compression devices to mimic walking pressures; D) Isometric exercises to compress vessels and reduce DVT risk. Heparin is typically subcutaneous, coughing/deep breathing prevents pulmonary issues, and compression stockings are beneficial unless PAD is present.
The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.