Nokea
Two days ago the client underwent femoral popliteal artery bypass graft surgery. What should be the nurse’s priority at this time?
- A. Monitor intake and output every four hours.
- B. Report any edema that develops in the operative leg.
- C. Place the client in a 60-degree sitting position when in bed.
- D. Check pedal and post tibial pulses bilaterally every 4 hours.
Correct Answer: D
Rationale: The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Checking both sides allows for comparison. I&O, edema, and positioning are secondary.
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The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client’s baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?
- A. BP 154/78 mm Hg
- B. Pedal pulses palpable at +1
- C. Left groin soft to palpation with 1 cm ecchymotic area
- D. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
Correct Answer: D
Rationale: An apical pulse of 132 bpm with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. Slight BP elevation, +1 pulses, and minor ecchymosis are less concerning without additional context.
The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.
The client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Correct Answer: 11
Rationale: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
The male client states to the nurse, “I’ve recovered after having my new artificial heart valve inserted. Now I want to have a vasectomy so I don’t get my wife pregnant.” What is the nurse’s best response?
- A. “That’s probably not a good idea. You could get an infection and damage the new valve.”
- B. “You seem relieved that surgery was successful and that you can enjoy a normal life again.”
- C. “Be sure to take a nitroglycerin tablet before sexual intercourse to prevent any chest pain.”
- D. “Inform your surgeon about the new valve so antibiotics are prescribed before the procedure.”
Correct Answer: D
Rationale: The surgeon should be aware of the artificial heart valve because antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The client is also taking an anticoagulant and would be at risk for bleeding. Other responses are incorrect or irrelevant.
The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.