Med Surg 29

A client was driving a car without wearing a seat belt and slid off of the road and hit a tree. The client's chest was crushed against a steering wheel. What type of lethal injury does the nurse anticipate the client may have suffered? A) Cardiac tamponade B) A pleural effusion C) Bladder trauma D) Fractured pelvis

A Feedback: A nonpenetrating injury of the chest, such as being crushed against a steering wheel, may cause bruising and bleeding of the heart. Because the pericardium encloses the heart, blood accumulates in the pericardial space, resulting in cardiac tamponade. Although a fractured pelvis and bladder trauma may be sustained, they are generally not lethal. A pleural effusion would not result from this traumatic injury. 36

One of the nursing students asks the nursing instructor why someone would need cardiac surgery. What would be an appropriate response by the nursing instructor? A) A ventricular aneurysm B) Mitral valve sufficiency C) An atrial aneurysm D) Endocarditis

A Feedback: A ventricular aneurysm is the most lethal complication among clients who survive the acute stage of a myocardial infarction (MI). Because the motion of the myocardium may rupture the aneurysm, an emergency procedure may be performed to suture the weakened area. If waiting is possible, the stretched tissue is excised 4 to 8 weeks after the MI when scar tissue has formed. If surgery is performed too early, it is difficult to differentiate healthy from necrotic tissue, and sutures placed in necrotic tissue usually are not retained. Mitral valve insufficiency produces a "backup" of blood within the left atrium but is not necessarily a cause for surgery. Atrial aneurysm is rare. Endocarditis is an infection and does not require surgery. 6

The nurse is answering questions that the client and family have about the upcoming cardiovascular surgery the client is having. What expected outcome would be best for a nursing diagnosis of Deficient Knowledge related to unfamiliarity with diagnostic tests, preoperative preparations, and postoperative care? A) Client and family will understand the purpose, preparation, and aftercare of tests and surgery. B) Provide verbal and written information concerning the surgical procedure and aftercare. C) Ask the client or family member to explain the surgical procedure before signing the consent form. D) Clarify misconceptions concerning surgery.

A Feedback: Client and family will understand the purpose, preparation, and aftercare of tests and surgery is an outcome statement that would be appropriate for the diagnostic statement. The other statements are all interventions that are associated with the diagnostic statement and outcome standard. 24

A client is diagnosed with obstructive atherosclerotic plaque of the left carotid artery. What procedure does the nurse anticipate preparing the client for? A) Endarterectomy B) Thrombectomy C) Embolectomy D) Coronary artery bypass graft

A Feedback: Endarterectomy is the resection and removal of the lining of an artery. This type of surgery is performed to remove obstructive atherosclerotic plaques from the aorta, carotid, femoral, or popliteal arteries. A thrombectomy is used to remove a thrombus for a vessel. An embolectomy is the removal of an embolus. Coronary artery bypass grafting is not indicated for the removal of an atherosclerotic plaque. 19

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.

A Feedback: 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, not 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. 28

A client has been discharged from the hospital following coronary artery bypass grafting (CABG). The client asks the nurse about the chest pain he experienced prior to coming to the hospital during the heart attack. What instructions should the nurse include in the instructions? A) "If chest pain occurs, rest. If it doesn't go away, take nitroglycerin and report the even to the physician even if the pain is relieved." B) "If chest pain occurs, take a nitroglycerin. If unrelieved, take another one 5 minutes later. If relieved, no further action is required." C) "If chest pain occurs, it may be related to gastritis. Take an antacid and lie down for 30 minutes." D) "You should not have chest pain because you had the CABG, and it fixed the problem with your heart."

A Feedback: If chest pain occurs after the client has had a CABG, the client should take a nitroglycerin, and even if relieved, the client need to report the incidence to the physician. Reocclusion of a vessel may occur, or a new myocardial infarction may occur from another vessel occlusion. If the pain is relieved, the client may have had a coronary vasospasm. The client should notify the physician for any chest pain even if it is relieved. The client should not attribute the pain to a gastrointestinal symptom and notify the physician. Chest pain may still occur as well as a myocardial infarction even after a CABG. 33

A client recently had a myocardial infarction (MI) and asks the nurse if he will require a heart transplant. Based on the nurse's knowledge of indications for heart transplant, what is the best response? A) "No. Heart transplant is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure." B) "No. Heart transplant is only indicated for congenital heart defects." C) "Yes. You may require a heart transplant if you have another heart attack." D) "Yes. Your heart will not function as well as it did before the heart attack, and a new heart will give you the best chance for survival."

A Feedback: In adults, heart transplantation is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure. In newborns and infants, heart transplantation is indicated for a severe congenital cardiac defect. It is performed only when other treatment modalities fail or are unavailable. It is not used to treat clients after an MI unless they meet any of the given criteria. 14

You are caring for an 81-year-old client who is deciding whether to have cardiovascular surgery. The client asks you why the risks are greater for them than for a younger person, what would be your answer? A) Many older adults have other things wrong with them besides their cardiac problems. B) Older adults have the same risk factors as younger adults. C) Older adults have hypersensitive renal systems, and younger adults don't. D) Older adults have different thought processes than younger adults do.

A Feedback: Many older adults have comorbidities such as diabetes, heart failure, cardiac dysrhythmias, hypertension, and poor renal function, necessitating careful consideration regarding the potential risks and benefits of cardiovascular surgery. These clients require close observation during the postoperative period. Options B, C, and D are incorrect. 8

A client will be placed on cardiopulmonary bypass for a mitral valve replacement. What type of medication will be required for this client? A) An anticoagulant B) A calcium channel blocker C) An antipyretic D) A beta-adrenergic blocker

A Feedback: One of the disadvantages of cardiopulmonary bypass is the need for anticoagulation. A calcium channel blocker, antipyretic, and beta-adrenergic blocker are not required for a client on cardiopulmonary bypass. 12

The nurse is preparing the client for discharge after cardiac transplant. The client has a prescription for tacrolimus (Prograf). What should the nurse include in the instructions? A) Do not take the medication with grapefruit juice. B) The medication may be crushed and put in chocolate milk. C) If a dose is skipped, you may double the next dose. D) Do not take any over-the-counter medications.

A Feedback: Tacrolimus (Prograf) should not be taken with grapefruit juice. Omit the morning dose when and until blood work is completed. The medication should not be crushed. A double dose should not be taken unless approved by the physician. There are some medications that may be taken but prior approval should be had by the physician. 16

The nurse is preparing a client for coronary artery bypass surgery. What vessel does the nurse know is most commonly used for grafting? A) Saphenous vein B) Basilic vein C) Radial artery D) Gastroepiploic artery

A Feedback: The saphenous vein in the leg is the vessel most often used for grafting in coronary artery bypass. The basilic vein in the arm, radial artery in the arm, and gastroepiploic artery from the stomach are alternative graft vessels. 34

A client is 2 days postoperative from mitral valve replacement and is in pain at an 8 on a 0 to 10 scale. What interventions can the nurse provide to control the pain before getting to this level? Select all that apply. A) Suggest the client be placed on a patient-controlled analgesia (PCA) pump. B) Administer a non-narcotic analgesic between prescribed doses of narcotic analgesics. C) Administer the pain medication prior to the pain becoming severe. D) Wait until the client asks for the pain medication. E) Administer the narcotic analgesic more frequently.

A, B, C Feedback: Small, frequent self-administration of an opioid drug controls acute pain within consistently tolerable levels. Administer non-narcotic analgesics between prescribed doses of narcotic analgesics. Non-narcotics have a different mechanism of action and are not likely to cause respiratory depression or depressed level of consciousness if given concurrently with narcotics. Pain is more easily controlled by giving analgesic medication before the pain becomes severe, so you would not wait until the client to ask for the pain medication. The nurse cannot administer more of the narcotic than the physician orders. 26

The pathophysiology instructor is discussing heart disease with a class of prenursing students. One of the students asks what indications there are for coronary artery bypass surgery with cardiopulmonary bypass. What would be the instructor's answer? Select all that apply. A) Atheromas are calcified and noncompressible. B) The heart cannot be repaired without compromising oxygenation of the body. C) The client has multiple coronary artery occlusions. D) Transluminal coronary angioplasty is necessary. E) The anatomic location of the occlusion(s) interferes with the safe insertion of a coronary artery catheter.

A, B, E Feedback: A coronary artery bypass is performed when (1) the client has multiple coronary artery occlusions, (2) the atheromas are calcified and noncompressible, or (3) the anatomic location of the occlusion(s) interferes with the safe insertion of a coronary artery catheter. This makes options B and D incorrect. 5

The nurse is caring for a client who is having a mitral valve replacement with a mechanical valve. What instructions should the nurse be sure the client understands prior to being discharged? A) The valve should last for 10 to 15 years. B) The client will require anticoagulation. C) There is a low potential for thrombi formations so anticoagulation is not necessary. D) The valve is prone to calcification.

B Feedback: A mechanical valve should last at least 20 years. The disadvantages are the risk for thrombi and emboli, so anticoagulation are necessary. There is a risk of bleeding, and there can be a sudden malfunction in the valve. An allograft will last 10 to 15 years. A bioprosthetic valve does not require anticoagulation but is prone to deterioration and calcification. 29

A client has experienced a myocardial infarction (MI). After the acute stage of the MI, what is the most lethal complication the nurse should be aware can occur? A) Thrombophlebitis B) Ventricular aneurysm C) Mitral valve prolapse D) Septic shock

B Feedback: A ventricular aneurysm is the most lethal complication among clients who survive the acute stage of a myocardial infarction (MI). Thrombophlebitis is a complication of immobility. Mitral valve prolapse is an acquired disorder that is not a complication from having an MI. Cardiogenic shock, not septic shock, is a complication after sustaining an MI. 13

A client had a cardiac transplant 6 weeks previously. The client calls the clinic and informs the nurse he has a fever of 101° F, chest tenderness, and flulike symptoms. What does the nurse suspect the client is experiencing? A) Hyperacute rejection B) Acute rejection C) Chronic rejection D) Subacute rejection

B Feedback: Acute rejection occurs from 1 week to 3 months after the transplant; almost all transplant recipients experience acute rejection to some degree. Hyperacute rejection is rare and occurs within a few minutes of the transplant when the donor organ and recipient are extremely mismatched. Chronic rejection may occur at any time over the remaining lifetime of a recipient, causing varying degrees of damage to the donor heart. Subacute rejection is not a classification of rejection. 15

The client is being prepared for cardiothoracic surgery and is very apprehensive. What medication can be administered with a physician's order to decrease the amount of anesthetic that the client will receive in surgery? A) An antipsychotic drug B) An anxiolytic drug C) An anticholinergic drug D) An analgesic

B Feedback: Anxiolytics may be used before surgery to lessen anxiety and sedate the client. Clients who are relaxed and sedated when anesthesia is given require a smaller dose of anesthetic. An antipsychotic would not be indicated for this client. An anticholinergic medication may be given to decrease the amount of secretions the client will have during surgery but will not decrease anxiety. An analgesic is normally given postoperatively for pain control. 25

A client is in the intensive care unit with a diagnosis of severe uncontrolled hypertension. What method of monitoring would best meet the needs of this client? A) Central venous pressure monitoring B) Direct blood pressure monitoring C) Pulmonary artery pressure monitoring D) Manual blood pressure readings with a sphygmomanometer

B Feedback: Direct blood pressure monitoring continuously displays the waveform and indicates the client's systolic, diastolic, and mean arterial pressures. This type of equipment eliminates the need to auscultate the BP. Direct BP monitoring may be used in clients with severe and sustained hypertension or hypotension and during and after cardiac surgery. Central venous pressure monitoring would be used to detect an excess or deficit in venous blood volume and would not be indicated for this client. Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances prevents left-sided heart failure or promotes its early correction and helps monitor the client's response to treatment and would not be indicated for this client. A manual reading is dependent on who takes the BP and can vary in its readings. It is not as accurate as the direct blood pressure monitoring. 20

A client has been admitted for a commissurotomy. You know that a commissurotomy repairs which of the following? A) A ventricle B) A valve C) Part of the myocardium D) An artery

B Feedback: 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. 9

A nurse caring for a client who has had cardiac surgery must understand how pulmonary artery pressure is monitored. What is important about pulmonary artery pressure? A) Aids in early treatment of right-sided congestive heart failure B) Aids in the early treatment of fluid imbalances C) Assesses right-sided heart pressures D) Assesses left atrial heart pressures

B Feedback: Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances, prevents left-sided congestive heart failure or promotes its early correction, and helps monitor the client's response to treatment. Options C and D are incorrect. The measurement of pulmonary artery pressure does not assess right-sided heart pressures or left atrial pressure. 11

A client had cardiothoracic surgery and informed the nurse that he has a 6-month-old grandchild. The client states, "I can't wait to hold my grandchild!" What is the best response by the nurse? A) "I bet your grandchild is wonderful, and I know you are glad you made it through the surgery." B) "I am sure you are excited to see your grandchild but you must refrain from lifting, pushing, or pulling anything over 10 lb for at least 6 to 12 weeks." C) "You will not be able to lift that grandchild for at least 6 months, but you can sit with him and play." D) "You have done so well after your surgery, and there are no restrictions for your activities."

B Feedback: The client must refrain from lifting, pushing, or pulling anything that weighs more than 10 lb until the physician relieves the restriction in approximately 6 to 12 weeks. Informing the client that he is glad he made it through the surgery is nontherapeutic. Six months for lifting is an excessive time frame for activity to resume. There are several restrictions that the client should be made aware of during the postoperative time period. 31

The nurse is measuring central venous pressure readings for a client receiving fluid resuscitation. Prior to obtaining the reading, what priority nursing action is required? A) Have the head of the bed at 90°. B) Ensure the level of the transducer is at the level of the right atrium. C) Ensure the transducer is above the level of the heart. D) Ensure the transducer is 2 inches below the level of the heart.

B Feedback: When measuring CVP, the nurse makes sure that the transducer is at the level of the client's right atrium; otherwise, an incorrect reading is obtained. The client is position supine or with the head slightly elevated but in exactly the same position as during previous measurements. Between CVP measurements, the head of the bed can be raised or lowered. 21

A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following? A) Blood sugar level B) Fluid intake and urine output C) Mentation D) Blood pressure and pulse rate in both arms

B Feedback: While accessing a client undergoing cardiac or vascular surgery, the nurse assesses the client's fluid intake and urine output on hourly basis. The nurse may assess the blood sugar level during the initial assessment process but not hourly. For a client undergoing a cardiac or vascular surgery, the nurse does not assess for mentation. The nurse assesses the client's blood pressure and pulse rate in both arms after thoracic surgery. 4

While teaching a pathophysiology class, you are asked what vessels are used for alternative grafts if the saphenous vein is not used. What would be your answer? Select all that apply. A) The popliteal vein B) The internal mammary artery C) The gastroepiploic artery D) The basilic and cephalic veins in the arm

B, C, D Feedback: 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. This makes option A incorrect. 7

A client is at the clinic for follow-up after cardiothoracic surgery and tells the nurse, "I don't know what is wrong with me. I don't want to eat, and I feel depressed." What is the best response by the nurse to this statement? A) "I think we need to get you in to see a psychiatrist." B) "There should be no reason for you to be depressed. You came through the surgery fine." C) "It may take several weeks for your appetite to return, and the depression is normal and temporary." D) "You need to tell the physician because this could be serious."

C Feedback: Discharge instruction should be given prior to the client leaving the hospital about it taking several weeks for a normal appetite to return and that depression is normal and temporary. The client does not need psychiatric help at this point but may benefit from a support group with other clients that have had cardiothoracic surgery. Informing a client that he has no reason for being depressed is nontherapeutic and demeans the client's feelings. Informing the physician because the depression could be serious could cause alarm. 30

After being discharged from the hospital after undergoing cardiothoracic surgery, the client asks the nurse when he can resume sexual activity. What is the best response by the nurse? A) "I can't believe you are worried about that so soon after your surgery." B) "You won't be able to resume sexual activity until your 6-month checkup with the surgeon." C) "In about 2 to 4 weeks if you are able to climb stairs without difficulty breathing or chest pain." D) "You may have a difficult time resuming sexual activities after this surgery."

C Feedback: Sexual relations usually can be resumed in 2 to 4 weeks depending on your comfort level and tolerance for activity; climbing two flights of stairs without dyspnea or chest pain is a common guideline. Option A and D are nontherapeutic responses to the client's concern. Six months is an excessively long time period to wait if the client has been able to resume activities without shortness of breath or chest pain. 32

The nurse is obtaining vital signs for a client in the clinic who has had a cardiac transplant. The nurse obtains an apical heart rate of 110 beats/minute. What is a priority action by the nurse? A) Obtain an electrocardiogram. B) Notify the physician. C) No action is required because the transplanted heart beats faster than the natural heart. D) Administer a calcium channel blocker to decrease the heart rate.

C Feedback: The transplanted heart beats faster than the client's natural heart, averaging about 100 to 110 beats/minute, because nerves that affect heart rate have been severed. The new heart also takes longer to increase the heart rate in response to exercise. If the client is asymptomatic, there is no reason to obtain an ECG or notify the physician. The nurse would not administer the calcium channel blocker without a physician's order. 18

A client has been waiting for a donor heart for several months. When he receives the call that a heart has become available, the client states, "How long do I have to get to the hospital?" What is the best response by the transplant nurse? 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."

C Feedback: When a donor heart becomes available, it must be removed from the donor and transplanted within 6 hours of being harvested. Answers A and D are too long of a time frame for the donor heart to be transplanted. It is unreasonable to expect a client to be in the hospital within 15 minutes and would be an incorrect time frame.

When discussing the nursing process, the instructor stresses that for clients undergoing cardiac surgery, it is important for the nurse to demonstrate competence. What is the rationale for this statement? A) To acknowledge the client's emotion B) To encourage verbal conversation C) To relieve the client's insecurity and anxiety D) To encourage the client to communicate

C Feedback: When the nurse is knowledgeable and competent, it relieves the client's insecurity and anxiety regarding the surgery. 3

A client will be taking mycophenolate (CellCept) to reduce the risk of rejection after a cardiac transplant. What should the nurse be sure to inform the client to report? A) Increase in appetite B) Swelling of the fingers C) A cough D) Unusual bleeding or bruising

D Feedback: CellCept may lower the platelet count. The client should be instructed to report any unusual bleeding or bruising. Cough, swelling of the fingers, or increase in appetite are not indicators of a low platelet count. 17

The nurse is caring for a client postoperatively after undergoing a coronary artery bypass graft. What intervention can the nurse provide to reduce the risk of the development of wound dehiscence? A) Encourage oral fluids. B) Assess lung sounds every 8 hours. C) Suction the client every 2 hours. D) Assist the client to splint with a pillow when coughing and deep breathing.

D Feedback: Instruct the client to press a pillow against the chest when deep breathing, coughing, and performing active exercise. Splinting promotes comfort and decreases the potential for dehiscence. Encouraging oral fluids will not prevent dehiscence. Lungs should be assessed every 4 hours or more frequently according to the client's condition. Suction should only be provided as needed. 27

The client will be having a surgical procedure that does not use cardiopulmonary bypass, and the surgeon keeps the heart at a rate of 40 beats/minute. What surgical procedure does the nurse anticipate preparing the client for? A) Port access coronary artery bypass (PACAB) B) Heart transplant C) Coronary artery bypass grafting D) Off-pump coronary artery bypass (OPCAB)

D Feedback: OPCAB is very similar to conventional CABG except that it does not involve the use of a cardiopulmonary bypass machine. Instead, the surgeon keeps the heart beating at a slow rate (about 40 beats/minute) with drugs such as adenosine (Adenocard) and esmolol (Brevibloc). The other answers require cardiopulmonary bypass. 35

A client 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.

D Feedback: 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, you may notify either. Administration of medications without a physician's order is contraindicated. 23

Bruising and bleeding of the heart may be caused by blunt trauma. What may stop the bleeding? A) Embolectomy B) Pericarditis C) Thoracentesis D) Inactivity and pressure from blood in the pericardium

D Feedback: The inactivity and increased pressure from blood in the pericardium may stop the bleeding. The client may need to have the blood aspirated from the pericardial sac, in which case pericardiocentesis is performed. One aspiration is sufficient in most cases, but if bleeding continues, open thoracotomy is indicated to control blood loss. Procedures to stop the bleeding caused by heart trauma do not include embolectomy or thoracentesis. Pericarditis is an inflammation of the pericardium. 10

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

D Feedback: 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. 2

A client has a pulmonary artery catheter for monitoring and to ensure fluid balance. When measuring pulmonary capillary wedge pressure, the nurse forgets to deflate the balloon and leaves it inflated. What outcome can be the result of this action by the nurse? A) Pulmonary embolism B) Pulmonary edema C) A myocardial infarction D) Pulmonary infarction

D Feedback: When measuring pulmonary capillary wedge pressure, the balloon must be deflated immediately after the pressure is measured to avoid pulmonary infarction from prolonged blockage of capillary blood flow. Pulmonary embolism, pulmonary edema, and myocardial infarction would not be the result of not deflating the balloon initially. 22