Nokea
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.
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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.
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 completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The client is admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.