Nokea
Which finding best indicates that cardiac compressions can be discontinued?
- A. The victim's color improves.
- B. The pupils become dilated.
- C. A pulse can be palpated.
- D. The victim begins to vomit.
Correct Answer: C
Rationale: A palpable pulse indicates spontaneous circulation, allowing CPR to be discontinued.
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An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
The nurse checking the client's leg incision is aware that which is the most common blood vessel used in CABG surgery?
- A. The saphenous vein
- B. The femoral artery
- C. The popliteal vein
- D. The iliac artery
Correct Answer: A
Rationale: The saphenous vein is commonly used in CABG due to its accessibility and suitability for grafting.
The nurse is observing a client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed doing what?
- A. Alternately dorsiflexing and plantar flexing the feet while the legs are elevated
- B. Massaging the legs beginning at the feet and moving toward the heart
- C. Alternately walking short distances and resting with the legs elevated
- D. Elevating the legs, then dangling them, and then lying flat for three minutes in each position
Correct Answer: D
Rationale: Buerger-Allen exercises involve elevating the legs to promote arterial emptying, dangling to promote filling, and lying flat to rest, performed in cycles to improve circulation.
A prothrombin time test should be performed regularly on persons who are taking which medication?
- A. Heparin
- B. Warfarin
- C. Phenobarbital
- D. Digoxin
Correct Answer: B
Rationale: A prothrombin time test is done to determine the effectiveness of warfarin. A partial thromboplastin time test is used for heparin. Phenobarbital and digoxin do not require regular clotting tests, though serum levels may be monitored for long-term therapy.
When the client asks the nurse how cholesterol acts as a cardiac risk factor, what is the best explanation?
- A. Excess fat in the blood expands the circulating blood volume.
- B. Excess fat in the blood thickens the lining of the arteries.
- C. Excess fat in the blood causes slower blood clotting.
- D. Excess fat in the blood stimulates the heart to beat faster.
Correct Answer: B
Rationale: High cholesterol contributes to atherosclerosis, where excess fat (lipids) deposits thicken and harden the arterial walls, narrowing the lumen and increasing cardiac risk.