Nokea
The nurse is measuring central venous pressure readings for a client receiving fluid resuscitation. Prior to obtaining the reading, what nursing action is required?
- A. Have the head of the bed at $90^{\circ}$.
- B. Ensure the level of the transducer is at the level of the right atrium.
- C. Ensure the transducer is above the level of the heart.
- D. Ensure the transducer is 2 inches below the level of the heart.
Correct Answer: B
Rationale: When measuring CVP, the nurse makes sure that the transducer is at the level of the client's right atrium; otherwise, an incorrect reading is obtained. The client is positioned supine or with the head slightly elevated but in exactly the same position as during previous measurements. Between CVP measurements, the head of the bed can be raised or lowered.
You may also like to solve these questions
A client is at the clinic for follow-up after cardiothoracic surgery and tells the nurse, 'I don't know what is wrong with me. I don't want to eat, and I feel depressed.' What is the best response by the nurse to this statement?
- A. I think we need to get you in to see a psychiatrist.
- B. There should be no reason for you to be depressed. You came through the surgery fine.
- C. It may take several weeks for your appetite to return, and the depression is normal and temporary.
- D. You need to tell the physician because this could be serious.
Correct Answer: C
Rationale: Discharge instruction should be given prior to the client leaving the hospital about it taking several weeks for a normal appetite to return and that depression is normal and temporary. The client does not need psychiatric help at this point but may benefit from a support group with other clients that have had cardiothoracic surgery. Telling a client there is no reason for being depressed is nontherapeutic and demeans the client's feelings. Telling the client to inform the physician because the depression could be serious could cause alarm.
When discussing the nursing process, the instructor stresses that for clients undergoing cardiac surgery, it is important for the nurse to demonstrate competence. What is the rationale for this statement?
- A. To acknowledge the client's emotion
- B. To encourage verbal conversation
- C. To relieve the client's insecurity and anxiety
- D. To encourage the client to communicate
Correct Answer: C
Rationale: When the nurse is knowledgeable and competent, it relieves the client's insecurity and anxiety regarding the surgery.
A client has experienced a myocardial infarction (MI). After the acute stage of the MI, what is the most lethal complication the nurse should be aware can occur?
- A. Thrombophlebitis
- B. Ventricular aneurysm
- C. Mitral valve prolapse
- D. Septic shock
Correct Answer: B
Rationale: A ventricular aneurysm is the most lethal complication among clients who survive the acute stage of a myocardial infarction (MI). Thrombophlebitis is a complication of immobility. Mitral valve prolapse is an acquired disorder that is not a complication from having an MI. Cardiogenic shock, not septic shock, is a complication after sustaining an MI.
The pathophysiology instructor is discussing heart disease with a class of prenursing students. One of the students asks what indications there are for coronary artery bypass surgery. What would be an acceptable answer(s) from the instructor? Select all that apply.
- A. Atheromas are calcified and noncompressible.
- B. The heart cannot be repaired without compromising oxygenation of the body.
- C. The client has multiple coronary artery occlusions.
- D. Transluminal coronary angioplasty is necessary.
- E. The Anatomic location of the occlusion(s) interferes with the safe insertion of a coronary artery catheter.
Correct Answer: A,B,E
Rationale: A coronary artery bypass is performed when (1) the client has multiple coronary artery occlusions, (2) the atheromas are calcified and noncompressible, or (3) the anatomic location of the occlusion(s) interferes with the safe insertion of a coronary artery catheter. This makes the other options incorrect.
The nurse is caring for a client who is having a mitral valve replacement with a mechanical valve. What instructions should the nurse be sure the client understands prior to being discharged?
- A. The valve should last for 10 to 15 years.
- B. The client will require anticoagulation.
- C. There is a low potential for thrombi formations so anticoagulation is not necessary.
- D. The valve is prone to calcification.
Correct Answer: B
Rationale: A mechanical valve should last at least 20 years. The disadvantages are the risk for thrombi and emboli, so anticoagulation is necessary. There is a risk of bleeding, and there can be a sudden malfunction in the valve. An allograft will last 10 to 15 years. A bioprosthetic valve does not require anticoagulation but is prone to deterioration and calcification.