Nokea
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.
You may also like to solve these questions
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?
- A. This test will find any congenital heart defects.
- B. This test can tell us a lot about your heart.
- C. Echocardiography is a way of determining the functioning of the left ventricle of your heart.
- D. Echocardiography will tell your doctor if you have cancer of the heart.
Correct Answer: C
Rationale: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. Explaining the procedure is the best answer because it addresses the client's question without making the client anxious or minimizing the question.
The nurse monitors a client with dark skin for signs of cyanosis. Which manifestation, documented by the nurse, indicates cyanosis for this client?
- A. Dark red lips and tongue
- B. Grayish cast to the skin
- C. Pale appearance to the skin
- D. Pale pink mucous membranes
Correct Answer: B
Rationale: A good light is necessary when monitoring skin color. Many clients with cardiac disorders exhibit changes in skin color (e.g., cyanosis, pallor). Cyanosis can be detected by carefully noting color changes in the oral mucous membranes as well as in the lips, earlobes, skin, and nail beds. In dark-skinned clients, a grayish cast to the skin indicates pallor. In clients who are light skinned, extreme pallor is easy to detect because the skin appears almost bloodless. Dark red lips and tongue are not manifestations associated with cyanosis. A pale appearance can indicate cyanosis for a client with light skin. The presence of pale pink mucous membranes is a normal or expected finding and is not associated with cyanosis.
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?
- A. A 48-year-old policemen with history of knee replacement 4 years ago
- B. A 68-year-old housewife with history of osteoporosis
- C. A 72-year-old retired janitor obtaining a cardiac baseline
- D. A 55-year-old recovering from a fall and broken femur
Correct Answer: D
Rationale: An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.
A client needs additional information about a heart condition. The client asks the nurse 'What is considered the pacemaker of the heart?'
- A. The AV node
- B. The bundle of HIS
- C. The Purkinje fibers
- D. The SA node
Correct Answer: D
Rationale: The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute.
The nurse is reviewing lab work for a client whose blood CO2 level is elevated. The nurse is most correct to suspect an impairment of which?
- A. Alveoli
- B. Bronchi
- C. The pulmonary artery
- D. The pulmonary vein
Correct Answer: A
Rationale: Gas exchange occurs in the lung where oxygen in inspired air exchanges for CO2 in the venous blood. The CO2 is then transferred to the alveoli to be exhaled. No gas exchange occurs in the bronchi. The pulmonary artery carries deoxygenated blood to the lungs, and the pulmonary vein brings oxygenated blood back to the heart to be pumped to the tissues.