Nokea
When the client returns to the room after the percutaneous transluminal coronary angioplasty (PTCA) procedure, which assessment finding should be reported immediately to the physician?
- A. Urine output of 100 mL/hour
- B. Blood pressure of 108/68 mm Hg
- C. Dry mouth
- D. Chest pain
Correct Answer: D
Rationale: Chest pain post-PTCA may indicate re-occlusion or complications like stent thrombosis, requiring immediate reporting.
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The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.
After the femoral artery has been cannulated and the client is returned to the room, what should the nurse plan to do first?
- A. Palpate the client's distal peripheral pulses10 pulses.
- B. Auscultate the client's heart and breath sounds.
- C. Percuss all four quadrants of the client's abdomen.
- D. Inspect the skin integrity in the client's groin.
Correct Answer: A
Rationale: Palpating distal pulses first ensures adequate circulation post-catheterization, detecting complications like arterial occlusion.
After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.
Which assessment finding would support the possibility of right-sided heart failure?
- A. Jugular vein distention
- B. Bradycardia
- C. Dry, hacking cough
- D. Flushed, red face
Correct Answer: A
Rationale: Jugular vein distention indicates increased venous pressure, typical of right-sided heart failure.