Nokea
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.
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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.
A client has been admitted for a commissurotomy. The nurse knows that a commissurotomy repairs which of the following?
- A. A ventricle
- B. A valve
- C. Part of the myocardium
- D. An artery
Correct Answer: B
Rationale: Heart valves need surgical repair or replacement if they become narrowed (stenosed) or stretched (incompetent). One method of repair is commissurotomy (opening adhesions in the valve cusps), which is done without direct visualization of the valve.
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.
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.
A client has been waiting for a donor heart for several months. Upon receiving the call that a heart has become available, the client asks the transplant nurse, 'How much time do I have to get to the hospital?' What answer should the nurse give the client?
- A. You can take your time. We have to get your heart so it could be 24 hours.
- B. You must be at the hospital within the next 15 minutes, or your heart will go the next person on the list.
- C. The heart has to be transplanted within 6 hours, so it is advisable that you go to the hospital to be prepared now.
- D. We can put the heart on ice and wait for you for 2 days.
Correct Answer: C
Rationale: When a donor heart becomes available, it must be removed from the donor and transplanted within 6 hours of being harvested. It is unreasonable to expect a client to be in the hospital within 15 minutes and would be an incorrect time frame.