Nokea
The nurse provides care for a client following a percutaneous transluminal coronary angioplasty (PTCA). Which is the priority action by the nurse?
- A. Monitor the gag reflex
- B. Evaluate for signs of infection
- C. Monitor for signs of fluid volume deficit
- D. Palpate distal pulses in bilateral extremities
Correct Answer: D
Rationale: The PTCA is an invasive nonsurgical procedure in which a balloon-tipped catheter is inserted and threaded through a peripheral artery. The nurse monitors the client for bleeding postprocedure in addition to palpating distal, bilateral pulses in the appropriate extremity. Fluid volume deficit is not a primary concern. This procedure does not require general anesthesia; therefore, monitoring for an impaired gag reflex is not a priority nursing action. Signs of infection should be monitored post-PTCA, but this is not an immediate concern.
You may also like to solve these questions
The client asks the nurse to explain the difference between arteriosclerosis and atherosclerosis. Which is the best explanation the nurse can give to the client?
- A. Both terms refer to the same disorder and can be used interchangeably
- B. Both are disorders in which the lining of the vessels become narrowed due to plaque
- C. Arteriosclerosis is when the vessels become dilated and weakened, whereas atherosclerosis is the deposit of fatty substances in the vessel lining
- D. Arteriosclerosis is a loss of elasticity of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the arteries fill with plaque
Correct Answer: D
Rationale: Arteriosclerosis refers to the loss of elasticity or hardening of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the lumen of arteries fills with fatty deposits called plaque. The two terms do not refer to the same disorder, nor can they be used interchangeably. The other responses provide the client with inaccurate information.
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
- A. Examine the client's mental and emotional status
- B. Examine the legs for color, capillary refill time, and tissue integrity
- C. Examine for pain around the shoulder and neck region
- D. Examine the extremities for skin lesions
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.
A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?
- A. I should avoid taking a tub bath until my catheter site heals
- B. I should expect a low-grade fever and swelling at the site for the next week
- C. I should avoid prolonged sitting
- D. I should expect bruising at the catheter site for up to 3 weeks
Correct Answer: B
Rationale: Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.
Which nursing assessment finding(s) suggests increased risk for coronary artery disease? Select all that apply.
- A. Arcus senilis
- B. Pear-shaped body
- C. Plump ear lobes
- D. Xanthelasma
- E. Sensory loss
- F. Motor changes
Correct Answer: A,D
Rationale: Arcus senilis is the opaque ring seen around the cornea that results from deposit of fat granules, and xanthelasma is raised yellow plaque on the eyelids. Both of these findings are suggestive of lipid accumulation that can increase the risk of CAD. An apple-shaped body carries a higher risk. Diagonal creases in the earlobe have been suggestive of CAD. Sensory and motor changes are more associated with CVA than CAD.
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?
- A. To dilate coronary arteries
- B. To decrease workload of the heart
- C. To decrease homocysteine levels
- D. To prevent angiotensin II conversion
Correct Answer: B
Rationale: Beta-adrenergic blockers are used in the treatment of CAD to decrease the consumption of myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.