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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.
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The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.
- A. Abrupt closure of the coronary artery
- B. Venous insufficiency
- C. Bleeding at the insertion site
- D. Retroperitoneal bleeding
- E. Arterial occlusion
Correct Answer: A,C,D,E
Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action?
- A. Document the patients low urine output and monitor closely for the next several hours
- B. Contact the dietitian and suggest the need for increased oral fluid intake
- C. Contact the patients physician and suggest assessment of fluid balance and renal function
- D. Increase the infusion rate of the patients IV fluid to prompt an increase in renal function
Correct Answer: C
Rationale: Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
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.
The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments?
- A. Maximizing cardiac output while minimizing heart rate
- B. Decreasing energy expenditure of the myocardium
- C. Balancing myocardial oxygen supply with demand
- D. Increasing the size of the myocardial muscle
Correct Answer: C
Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with productivity.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
- A. Nervousness or paresthesia
- B. Throbbing headache or dizziness
- C. Drowsiness or blurred vision
- D. Tinnitus or diplopia
Correct Answer: B
Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.