Nokea
Which of the following actions should the nurse take for a client immediately postoperative following a coronary artery bypass graft surgery (CABG)? Select all that apply.
- A. Obtain the client's capillary blood glucose
- B. Provide tracheostomy care, as needed
- C. Teach the client about the driving restrictions after this procedure
- D. Ground the epicardial pacing wires to the pacemaker generator
- E. Ensure patency of the mediastinal chest tubes
Correct Answer: A,D,E
Rationale: Monitoring blood glucose is crucial, especially in clients with diabetes or stress-induced hyperglycemia post-CABG. B: Incorrect - Tracheostomy care is not typically required unless the client has a tracheostomy, which is not indicated here. C: Incorrect - Teaching about driving restrictions is important but not an immediate postoperative priority. D: Correct - Grounding epicardial pacing wires ensures proper pacemaker function if temporary pacing is needed. E: Correct - Ensuring mediastinal chest tube patency prevents complications like tamponade or hemothorax.
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The nurse is caring for a client in the emergency department, reporting a headache and generalized flushing. The nurse should request a prescription for which medication? See the exhibit for additional client information.
- A. enalapril
- B. labetalol
- C. amiodarone
- D. nitroglycerin
Correct Answer: B
Rationale: Headache and flushing in a hypertensive crisis suggest the need for labetalol, a beta-blocker, to control blood pressure.
The nurse is caring for a client with Buerger's disease. The nurse plans on suggesting that the client receives a referral for
- A. occupational therapy.
- B. speech therapy.
- C. smoking cessation.
- D. group psychotherapy.
Correct Answer: C
Rationale: Buerger's disease is strongly linked to smoking, so cessation is critical to prevent disease progression.
The nurse has instructed a client with hyperlipidemia about self-management. Which statement by the client would require follow-up by the nurse?
- A. I should replace hydrogenated vegetable oils with canola oil when cooking.
- B. I should increase my intake of fish like tuna and salmon more often.
- C. Increasing my fiber intake will help lower my cholesterol.
- D. I am glad that I won't need to reduce red meat from my diet.
Correct Answer: D
Rationale: Red meat is high in saturated fat, which worsens hyperlipidemia. The client needs dietary education.
The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client
- A. with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour.
- B. recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT).
- C. with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute.
- D. who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.
Correct Answer: B
Rationale: Ventricular tachycardia is life-threatening and requires immediate PHCP notification, unlike the other less urgent findings.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse identifies this tracing as
- A. sinus tachycardia.
- B. supraventricular tachycardia.
- C. ventricular tachycardia.
- D. atrial flutter.
Correct Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia requiring immediate intervention, characterized by wide QRS complexes on ECG.