Nokea
The nurse reinforces teaching for a client who is scheduled for coronary artery bypass surgery. The client asks, 'What vessels can be used if my saphenous vein doesn't meet the requirements?' Which vessel(s) should the nurse include in the response to the client? Select all that apply.
- A. The basilic vein
- B. The axillary vein
- C. The popliteal vein
- D. The gastroepiploic artery
- E. The internal thoracic artery
Correct Answer: A,D,E
Rationale: Alternative graft vessels include the following: the internal mammary and internal thoracic arteries in the chest; the basilic and cephalic veins in the arm, the radial artery in the arm, and the gastroepiploic artery from the stomach, in some cases. The axillary and popliteal veins are not alternative graft vessels; therefore, the nurse should not include them in the response to the client.
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A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following?
- A. Blood sugar level
- B. Fluid intake and urine output
- C. Mentation
- D. Arterial blood gases
Correct Answer: B
Rationale: While assessing a client undergoing cardiac or vascular surgery, the nurse assesses the client's fluid intake and urine output on an hourly basis. The nurse may assess the blood sugar level during the initial assessment process but not hourly. For a client undergoing a cardiac or vascular surgery, the nurse does not assess for mentation. Arterial blood gases would not be assessed hourly.
The nursing instructor is giving a class on assessing cardiac clients after thoracic surgery. What assessment is most important for the nurse to perform when caring for this client?
- A. Pulmonary artery pressure
- B. Temperature
- C. Skin and mentation
- D. Blood pressure
Correct Answer: D
Rationale: The nurse assesses the blood pressure (BP) and pulse rate in both arms after thoracic surgery. Although it is necessary for the nurse to also assess pulmonary artery pressure, temperature, skin, and mentation after thoracic surgery, blood pressure and pulse rate are the most essential assessments.
A client is in the intensive care unit with a diagnosis of severe uncontrolled hypertension. What method of monitoring would best meet the needs of this client?
- A. Central venous pressure monitoring
- B. Direct blood pressure monitoring
- C. Pulmonary artery pressure monitoring
- D. Manual blood pressure readings with a sphygmomanometer
Correct Answer: B
Rationale: Direct blood pressure monitoring continuously displays the waveform and indicates the client's systolic, diastolic, and mean arterial pressures. This type of equipment eliminates the need to auscultate the BP. Direct BP monitoring may be used in clients with severe and sustained hypertension or hypotension and during and after cardiac surgery. Central venous pressure monitoring would be used to detect an excess or deficit in venous blood volume and would not be indicated for this client. Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances prevents left-sided heart failure or promotes its early correction and helps monitor the client's response to treatment and would not be indicated for this client. A manual reading is dependent on who takes the BP and can vary in its readings. It is not as accurate as the direct blood pressure monitoring.
A client has just had cardiothoracic surgery and tells the nurse about having a 6-month-old grandchild. The client states, 'I can't wait to hold my grandchild!' What is the best response by the nurse?
- A. I bet your grandchild is wonderful, and I know you are glad you made it through the surgery.
- B. I am sure you are excited to see your grandchild, but you must refrain from lifting, pushing, or pulling anything over 10 pounds for at least 6 to 12 weeks.
- C. You will not be able to lift that grandchild for at least 6 months, but you can sit with him and play.
- D. You have done so well after your surgery, and there are no restrictions for your activities.
Correct Answer: B
Rationale: The client must refrain from lifting, pushing, or pulling anything that weighs more than 10 lb. until the physician relieves the restriction in approximately 6 to 12 weeks. Telling the client 'I know you are glad you made it through the surgery' is not an informative or therapeutic response. Six months for lifting is an excessive time frame for activity to resume. There are several restrictions that the client should be made aware of during the postoperative time period.
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.