Nokea
The nurse listens to the lung sounds of a postoperative client and determines that the client is not able to clear the secretions from the lungs. What intervention should the nurse provide prior to suctioning?
- A. Hyperoxygenate the client with $100% oxygen.
- B. Place the client in the supine position.
- C. Plan to suction for at least 20 seconds to remove secretions.
- D. Administer a sedative prior to suctioning.
Correct Answer: A
Rationale: Hyperoxygenate with $100% oxygen before suctioning; do not suction for more than 10 to 15 seconds. Suctioning removes oxygen and can cause hypoxemia, myocardial ischemia, and dysrhythmias. Hyperoxygenation saturates the blood and hemoglobin to compensate for temporary removal during suctioning. Elevate the head of the bed; don't place the client in the supine position. Administering a sedative may cause respiratory depression and should be avoided prior to suctioning so the cough reflex will not be depressed.
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The nurse is answering questions that the client and family have about the upcoming cardiovascular surgery the client is having. What expected outcome would be best for a nursing diagnosis of Knowledge Deficiency related to unfamiliarity with diagnostic tests, preoperative preparations, and postoperative care?
- A. Client and family will understand the purpose, preparation, and aftercare of tests and surgery.
- B. Provide verbal and written information concerning the surgical procedure and aftercare.
- C. Ask the client or family member to explain the surgical procedure before signing the consent form.
- D. Clarify misconceptions concerning surgery.
Correct Answer: A
Rationale: Client and family will understand the purpose, preparation, and aftercare of tests and surgery is an outcome statement that would be appropriate for the diagnostic statement. The other statements are all interventions that are associated with the diagnostic statement.
A client is diagnosed with obstructive atherosclerotic plaque of the left carotid artery. What procedure does the nurse anticipate preparing the client for?
- A. Endarterectomy
- B. Thrombectomy
- C. Embolectomy
- D. Coronary artery bypass graft
Correct Answer: A
Rationale: Endarterectomy is the resection and removal of the lining of an artery. This type of surgery is performed to remove obstructive atherosclerotic plaques from the aorta, carotid, femoral, or popliteal arteries. A thrombectomy is used to remove a thrombus for a vessel. An embolectomy is the removal of an embolus. Coronary artery bypass grafting is not indicated for the removal of an atherosclerotic plaque.
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.
The nurse is caring for a client who has had cardiothoracic surgery, and the nurse is palpating the peripheral pulses. The nurse cannot palpate the left lower extremity pulse. What is the first action by the nurse?
- A. Call the physician.
- B. Call the charge nurse.
- C. Apply a vasodilator such as nitroglycerin cream on the skin surface and then palpate.
- D. Use a Doppler ultrasound device.
Correct Answer: D
Rationale: Palpate the peripheral pulses or use a Doppler ultrasound device if the pulses are not palpable. Prior to calling the physician or notifying the charge nurse, attempt to use the Doppler, and then, if no pulse is heard, the nurse may notify either. Administration of medications without a physician's prescription is contraindicated.
A client recently had a myocardial infarction (MI) and asks the nurse if he will require a heart transplant. Based on the nurse's knowledge of indications for heart transplant, what is the best response?
- A. No. Heart transplant is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure.
- B. No. Heart transplant is only indicated for congenital heart defects.
- C. Yes. You may require a heart transplant if you have another heart attack.
- D. Yes. Your heart will not function as well as it did before the heart attack, and a new heart will give you the best chance for survival.
Correct Answer: A
Rationale: In adults, heart transplantation is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure. In newborns and infants, heart transplantation is indicated for a severe congenital cardiac defect. It is performed only when other treatment modalities fail or are unavailable. It is not used to treat clients after an MI unless they meet any of the given criteria.