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The nurse provides care for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which clinical finding should the nurse anticipate relating to the infarction location?
- A. Jugular vein distention
- B. Irregular heart rate
- C. Peripheral edema
- D. Fever
Correct Answer: B
Rationale: The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Jugular vein distension and peripheral edema are anticipated for the client who is experiencing heart failure, not myocardial infarction (MI). Although fever can increase the client's heart rate, this is not an expected finding with an MI.
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The nurse provides care for a post-cardiac catheterization male client in the postprocedure room. Which is a priority nursing action for this client?
- A. Evaluate the client's temperature.
- B. Encourage the client to drink fluids.
- C. Advise the client to void while lying flat with a urinal.
- D. Monitor the client's pressure dressing.
Correct Answer: D
Rationale: Following cardiac catheterization, the client has a pressure dressing placed over the catheter site to control bleeding. After the procedure, the nurse checks the dressing over the insertion site frequently for signs of bleeding. Additionally, the nurse monitors the client's blood pressure (BP) and pulse frequently to detect complications; however, it is not a priority for the nurse to monitor the client's temperature after this procedure. Although the client is encouraged to drink fluids as part of the discharge instructions to assist with flushing the dye used during the procedure, this is not a priority nursing action for this client in the postprocedure period of care. The client is taught to void while lying flat using a urinal; however, this is not the priority action based on the current data.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
- A. Distention of the jugular vein
- B. Effort to lie down to breathe
- C. Right-sided heart failure
- D. Blood congestion in neck veins
Correct Answer: C
Rationale: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.
The nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?
- A. It is an indication of an impending heart failure.
- B. The client may develop anxiety disorder.
- C. It may indicate a problem with oxygenation.
- D. It creates anxiety during the diagnostic testing.
Correct Answer: C
Rationale: The nurse should report extremes in thought processes to the physician because such effects may interfere with the client's safety and prescribed therapy. Chest pain and impaired breathing may create anxiety. Extremes of emotions or disturbances in thought processes are not the indications of an impending heart failure. The client will not develop any anxiety disorder.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?
- A. Eat only soft foods for the next 12 hours.
- B. Report any numbness, tingling, or sharp pain in the extremity.
- C. Restrict your intake of water until the dye is out of the body.
- D. Move around whenever the client feels like getting up.
Correct Answer: B
Rationale: Instructions for the client and family include: Keep the extremity straight for several hours and avoid movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no need to eat only soft foods after a cardiac catheterization.
The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a comorbidity of multiple sclerosis, so the nurse knows the stress test will be drug induced. What drug will be used to dilate the coronary arteries?
- A. Thallium
- B. Lorazepam
- C. Diazepam
- D. Dobutamine
Correct Answer: D
Rationale: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. The other drugs would not dilate the coronary arteries.