Nokea
The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.
- A. Use a soft toothbrush for dental hygiene.
- B. Floss teeth daily to prevent plaque.
- C. Wear loose-fitting T-shirts or tops.
- D. Use an electric razor for shaving.
- E. Consume foods high in vitamin K.
Correct Answer: A;C;D
Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.
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The client is scheduled for a coronary artery bypass graft in one week. Which instructions should the nurse provide to the client? Select all that apply.
- A. Stop taking aspirin now and any products containing aspirin.
- B. Do perform aerobic exercises 30 minutes daily before surgery.
- C. Use the prescribed antimicrobial soap before hospital arrival.
- D. Shave your chest and legs and then shower to remove the hair.
- E. Resume normal activities when discharged from the hospital.
Correct Answer: A;C
Rationale: The nurse should instruct: A) Stop aspirin to reduce bleeding risk; C) Use antimicrobial soap to decrease infection risk. Aerobic exercises (B) may be too strenuous, shaving (D) is done just before surgery, and normal activities (E) are restricted post-surgery.
The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?
- A. Draw blood for cardiac enzymes STAT
- B. Call the cardiac catheterization laboratory
- C. Apply 1 inch of nitroglycerin paste topically
- D. Apply 4 liters of oxygen via nasal cannula
Correct Answer: D
Rationale: The nurse’s priority intervention should be to increase oxygen to the heart muscle. Applying 4 liters of oxygen via nasal cannula addresses the immediate need to improve myocardial oxygenation in an evolving MI indicated by ST elevation. Cardiac enzymes, catheterization, and nitroglycerin are secondary actions.
The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: D
Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.
The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?
- A. Restart heparin therapy as soon as possible.
- B. Reinforce the abdominal incision dressing.
- C. Inspect the groin insertion site for bleeding.
- D. Increase fluids to promote excretion of the dye.
Correct Answer: C
Rationale: The procedure for placement of a vena cava filter is done percutaneously, usually through the subclavian or femoral vein approach. The nurse should check the groin insertion site for bleeding. Heparin is unnecessary, there’s no abdominal incision, and dye is not used.