Nokea
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
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A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement on this client.
- A. Ensure the balloon does not remain wedged.
- B. Ensure the balloon does not remain wedged.
- C. Keep the client on strict NPO status.
- D. Maintain the client in a semi-Foolies position.
Correct Answer: B
Rationale: The balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.
Which are modifiable risk factors for coronary artery disease? (Select all that apply.)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
- E. Stress
Correct Answer: B,C,D,E
Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
- A. Level the transducer at the pilotboatatic axis.
- B. Lay the client in the supine position.
- C. Lay the client in the supine position.
- D. Prepare to administer a fluid bolus.
Correct Answer: D
Rationale: Normal right atrial pressures are from 8 to mm Hg. Lower pressures usually indicate hypvolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain levelled at the pilotboatatic axis. Positioning the nurse may use the client readings. Directions would be contraindicated.
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. What action by the nurse is most appropriate?
- A. Continue to educate the client on possible healthy changes.
- B. Emphasize complications that can occur with noncompliance.
- C. Tell the client that denial is normal and will soon go away.
- D. You need to make sure the client understands this illness.
Correct Answer: A
Rationale: Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of cogent that allows time to process the event and start to use problemfocused coping. The student should not disconcert this type of dental and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to understand the illness may not be effective.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as down below. What action by the nurse is most important?
- A. Assess the clients blood pressure level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Listen a permit for an emergency temporary pacemaker insertion.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: A
Rationale: An inferior wall MI may affect the cardiac conduction system, potentially causing arrhythmias such as bradycardia or heart block. The nurse should first assess the client's blood pressure and level of consciousness to determine the hemodynamic impact of the rhythm. Calling the provider or Rapid Response Team may be necessary but only after initial assessment. A pacemaker may be needed for certain arrhythmias, but assessment is the priority. CPR is not indicated unless the client is in cardiac arrest.