Nokea
The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
- A. Lipids and fibrous tissue
- B. White blood cells
- C. Lipoproteins
- D. High-density cholesterol
Correct Answer: A
Rationale: As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.
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The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care?
- A. With the patient, clarify the surgical procedure that will be performed
- B. Withhold the patients scheduled medications for at least 12 hours preoperatively
- C. Inform the patient that health teaching will begin as soon as possible after surgery
- D. Avoid discussing the patients fears as not to exacerbate them
Correct Answer: A
Rationale: Preoperatively, it is necessary to evaluate the patients understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the patients medication regimen if necessary; this will vary from patient to patient. Fears should be addressed directly and empathically.
A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk?
- A. Administration of bronchodilators by nebulizer
- B. Administration of inhaled corticosteroids by metered dose inhaler (MDI)
- C. Patients consistent performance of deep breathing and coughing exercises
- D. Patients active participation in the cardiac rehabilitation program
Correct Answer: C
Rationale: Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
- A. Brachial artery
- B. Brachial vein
- C. Femoral artery
- D. Greater saphenous vein
Correct Answer: D
Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?
- A. He will remain on bed rest for 48 to 72 hours after the procedure
- B. He will be given vitamin K infusions to prevent bleeding following PCI
- C. A sheath will be placed over the insertion site after the procedure is finished
- D. The procedure will likely be repeated in 6 to 8 weeks to ensure success
Correct Answer: C
Rationale: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are administered during PCI.
The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
- A. Dyspnea
- B. Unusual fatigue
- C. Hypotension
- D. Syncope
- E. Peripheral cyanosis
Correct Answer: A,B,D
Rationale: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.