LIPPINCOTT Adult Cardiac
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that: a) The client will remain in the ICU for 5 days. b) The client will sleep most of the time while in the ICU c) Noise and activity within the ICU are minimal. d) The client will receive medication to relieve pain.
Answer: The client will receive medication to relieve pain. Rationale: Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: a) A manual toothbrush. b) An electric toothbrush. c) An irrigation device. d) Dental floss.
Answer: A manual toothbrush. Rationale: Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis.
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period? a) Assess the temperature in the affected arm. b) Monitor the radial pulse in the affected arm. c) Protect the extremity from cold. d) Avoid using the arm for a venipuncture.
Answer: Avoid using the arm for a venipuncture. Rationale: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: a) Atrophy. b) Contraction. c) Gangrene. d) Rubor.
Answer: Gangrene. Rationale: The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin
Which of the following increases the risk of having a large abdominal aortic aneurysm rupture? a) Anemia. b) Dehydration. c) High blood pressure. d) Hyperglycemia.
Answer: High blood pressure. Rationale: In the preoperative phase, the goal is to prevent rupture. The client is placed in a semi-Fowler's position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for rupture.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: a) Administer epinephrine. b) Inform the physician. c) Administer oxygen. d) Inform the client that the procedure is almost over.
Answer: Inform the physician Rationale: Clients may have an immediate or a delayed reaction to the radiopaque dye. The physician should be notified immediately because the symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine. Explaining that the procedure is over does not address the current symptoms.
The client asks the nurse, "Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?" The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on: a) The need to remove as much of the leg as possible. b) The adequacy of the blood supply to the tissues. c) The ease with which a prosthesis can be fitted. d) The client's ability to walk with a prosthesis
Answer: The adequacy of the blood supply to the tissues. Rationale: The level of amputation commonly cannot be accurately determined until surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. A longer residual limb facilitates prosthesis fitting and will make it easier for the client to walk. However, although these aspects will be considered in the final decision, they are not the primary factors influencing the decision.
A client with peripheral vascular disease is recovering from an aorto-femoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information? a) "How did you manage your health before admission?" b) "How far could you walk without pain before surgery?" c) "What is your home environment like?" d) "Do you have problems with urine retention?"
"Answer: How did you manage your health before admission?" Rationale: Assessing the individual's health behavior before surgery will help the nurse and client develop strategies to manage the postoperative course. Asking open-ended questions will illicit the most helpful information. The client's ability to walk after surgery will be improved after surgery. The nurse can ask direct questions after obtaining general information
A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Urine output. 2. Peripheral pulses. 3. Urine output. 4. Incision site.
Answer: 2. Peripheral pulses. 4. Incision site. 3. Urine output. 1. Urine output. Rationale: Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make sure that the bypass graft is functioning, this step should be done first. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output. Lastly, the nurse should determine the client's level of pain.
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? a) Auscultate the pulses with a stethoscope. b) Call the physician. c) Use a Doppler ultrasound device. d) Inspect the lower left extremity.
Answer: Use a Doppler ultrasound device. Rationale: When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client's condition
While the nurse is providing preoperative teaching, the client says, "I hate the idea of being an invalid after they cut off my leg." The nurse's most therapeutic response should be: a) "You'll still have one good leg to use." b) "Tell me more about how you're feeling." c) "Let's finish the preoperative teaching." d) "You're fortunate to have a wife who can take care of you."
Answer: "Tell me more about how you're feeling." Rationale: Encouraging the client who is undergoing amputation to verbalize feelings is the most therapeutic nursing intervention. By eliciting concerns, the nurse may be able to provide information to help the client cope. The nurse should avoid value laden responses, such as "You'll still have one good leg," that may make the client feel guilty or hostile and block further communication. The nurse should not ignore the client's expressed concerns, nor should the nurse reinforce the client's concern about invalidism and dependency or assume that his wife is willing to care for him.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action? a) A low, grade 1 intensity mitral regurgitation murmur. b) SpO2 is 94% on 2 liters of oxygen via nasal cannula. c) The client has become more somnolent. d) Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Answer: The client has become more somnolent. Rationale: A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern.
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
Answer: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb's point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for: a) Alteration in renal perfusion. b) Electrolyte imbalance. c) Ineffective coping. d) Wound infection.
Answer: Alteration in renal perfusion. Rationale: Following surgical repair of an aortic aneurysm, there is a potential for an alteration in renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during surgery. Electrolyte imbalance, ineffective coping, and wound infection may occur after any surgery and do not present imminent risk for this client.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below: History And Physical 1) Smokes four cigars a month. 2) Vital signs: blood pressure, ranges from 150/76 mm Hg to 170/98 mm Hg; heart rate, 90 to 100 beats per minute; respirations, 12-18 per minute; temperature, 99.9° F (37.8° C). 3) +1 bilateral ankle edema. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan? a) Food intake b) Fluid volume c) Skin integrity d) Tissue perfusion
Answer: Tissue perfusion Rationale: The underlying pathophysiology in this client is atherosclerosis. The findings from the assessment indicate the risk factors of smoking and high blood pressure. Therefore, tissue perfusion is a priority for health promoting education. The data do not support education that focuses on food or fluid intake. Although edema is a potential problem and could contribute to poor skin integrity, the edema will likely be resolved by the aneurysm repair.
Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first: a) Assess the urine output. b) Place a large bore I.V. c) Position onto the left side. d) Insert a nasogastric tube.
Answer: Place a large bore I.V. Rationale: The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An I.V. should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with severe nausea and vomiting to decompress the stomach.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately: a) Apply a tourniquet. b) Assess vital signs. c) Call the physician. d) Elevate the surgical extremity with a large pillow.
Answer: Assess vital signs. Rationale: The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the physician. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client: a) Selects a low-cholesterol diet to control coronary artery disease. b) States a need for bed rest for 1 week after discharge. c) Verbalizes safety precautions needed to prevent pacemaker malfunction. d) Explains signs and symptoms of myocardial infarction (MI).
Answer: Verbalizes safety precautions needed to prevent pacemaker malfunction. Rationale: Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb or stretching and bending and to count the pulse once per week, that are necessary to maintain proper pacemaker function. The client will not necessarily be placed on a low cholesterol diet. The client should resume activities as he is able, and does not need to remain on bed rest. The client should know signs and symptoms of MI, but is not at risk because of the pacemaker.
The client has had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client in stump care. Which of the following statements by the client indicates that she understands how to implement her plan of care? a) "I should inspect the incision carefully when I change the dressing every other day." b) "I should wash the incision, dry it, and apply moisturizing lotion daily." c) "I should rewrap the stump as often as needed." d) "I should elevate the stump on pillows to decrease swelling."
Answer: "I should rewrap the stump as often as needed." Rationale: The purpose of wrapping the stump is to shape the residual limb to accept a prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing should be changed daily to allow for inspection of the stump incision. No lotions should be applied to the stump unless specifically ordered by the physician. The stump should not be elevated on pillows because this will contribute to the formation of flexion contractures. Contractures will prevent the client from wearing a prosthesis and ambulating.
Three days after mitral valve surgery, a 45-year-old female comments that she hears a "clicking" noise coming from her chest and her "rather large" chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? a) Anxiety related to altered body image. b) Anxiety related to altered health status. c) Altered tissue perfusion. d) Lack of knowledge regarding the postoperative course.
Answer: Anxiety related to altered body image. Rationale: Verbalized concerns from this client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectivenss of this medication by assessing the client for: a) Relief of anxiety. b) Sedation. c) Vasoconstriction. d) Vasodilation.
Answer: Vasodilation. Rationale: Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries. As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues. Diltiazem is not an antianxiety agent and does not promote sedation. It also does not cause vasoconstriction, which would be contraindicated for the client with PVD.
A client is admitted to the hospital with peripheral vascular disease (PVD) of the lower extremities. He is scheduled for an amputation of the left leg. The client says, "I've really tried to manage my condition well." Which of the following routines should the nurse evaluate as having been appropriate for him? a) Resting with his legs elevated above the level of his heart. b) Walking slowly but steadily for 30 minutes twice a day. c) Minimizing activity. d) Wearing antiembolism stockings at all times when out of bed.
Answer: Walking slowly but steadily for 30 minutes twice a day. Rationale: Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral arterial disease.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority? a) Assess the 12-lead EKG. b) Assess the blood pressure. c) Assess the lung sounds. d) Assess the urine output.
Answer: Assess the blood pressure. Rationale: The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. Vital Signs Date: 05/07/07 Time: 10:00 am Blood pressure 160/90 mm Hg Heart rate 74 bpm Respirations 20 per minute G. Fuentes, RN At 10:30 a.m., the client complains of sharp mid-chest pain after having a bowel movement. What should the nurse do first? a) Assess the client's vital signs. b) Administer a bolus of lactated Ringer's solution. c) Assess the client's neurologic status. d) Contact the physician.
Answer: Assess the client's vital signs. Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer's solution would require a physician's order.
A client has sudden, severe pain in his back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is: a) Cardiac tamponade. b) Stroke. c) Pulmonary edema. d) Myocardial infarction.
Answer: Cardiac tamponade. Rationale: Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following pre-procedure tasks? Select all that apply. a) Administer all ordered oral medications. b) Check for iodine sensitivity. c) Verify that written consent has been obtained. d) Withhold food and oral fluids before the procedure. e) Insert a urinary drainage catheter.
Answer: Check for iodine sensitivity; Verify that written consent has been obtained; Withhold food and oral fl uids before the procedure. Rationale: For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifi cally ordered. A urinary drainage catheter is rarely required for this procedure
A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. a) Begin Warfarin (Coumadin). b) Check the postoperative CBC, INR, PTT, & platelet levels. c) Confirm availability of blood products. d) Monitor the mediastinal chest tube drainage. e) Start a Dopamine (Intropin) drip for a systolic BP < 100.
Answer: Check the postoperative CBC, INR, PTT, & platelet levels; Confirm availability of blood products; Monitor the mediastinal chest tube drainage. Rationale: The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR & PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding, therefore availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Coumadin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
A client has undergone an amputation of several toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated for her while sitting in a chair? a) Crossing the legs. b) Elevating the legs. c) Flexing the ankles. d) Extending the knees.
Answer: Crossing the legs. Rationale: Leg crossing is contraindicated because it causes adduction of the hips and decreases the flow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg. Elevating the legs, flexing the ankles, and extending the knees are not necessarily contraindicated.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? a) Ensure a liberal fluid intake. b) Provide an alkaline-ash diet. c) Prevent constipation. d) Enrich the client's diet with dairy products.
Answer: Ensure a liberal fluid intake. Rationale: In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests an order for a different, or stronger, pain medication. The physician tells the nurse that the current order for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should next: a) Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered. b) Ask the hospitalist to write an order for a stronger pain medication. c) Wait until the next shift and ask the nurse on that shift to contact the physician. d) Report the incident to the team leader.
Answer: Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered. Rationale: The nurse is the client's advocate in planning for pain relief. When presented with a communications conflict, the nurse should first restate the concern, providing as much information as needed. If the physician still does not offer an acceptable solution for pain management the nurse can then discuss the situation with the hospitalist on the team and report the incident to the team leader. Waiting until the next shift to handle the problem does not contribute to the goal of managing the client's pain.
A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client: a) If he has improved circulation in the legs. b) If he can wiggle his toes. c) If he is urinating more frequently. d) If he is less dizzy.
Answer: If he has improved circulation in the legs. Rationale: Although pentoxifylline's (Trental) precise mechanism of action is unknown, its therapeutic effect is to increase blood flow, and the client should have improved circulation in the legs. The client does not have nerve impairment, and should be able to wiggle his toes. Urination is not improved by taking pentoxifylline. Dizziness is a side effect of the drug, not an intended outcome.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of post-surgery activity restrictions. Which of the following should the client not engage in until after the 1-month post-discharge appointment with the surgeon? a) Showering. b) Lifting anything heavier than 10 lb. c) A program of gradually progressive walking. d) Light housework.
Answer: Lifting anything heavier than 10 lb. Rationale: Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: a) Loss of consciousness. b) Anxiety. c) Headache. d) Disorientation.
Answer: Loss of consciousness Rationale: If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.
A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: a) Maintain skin integrity. b) Maintain cardiac conduction stability. c) Decrease cardiac output. d) Increase activity level
Answer: Maintain cardiac conduction stability. Rationale: Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to: a) Maintain circulation. b) Prevent infection. c) Relieve pain. d) Provide education.
Answer: Maintain circulation Rationale: Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.
A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the physician before having: a) Blood drawn. b) An I.V. line inserted. c) Major dental work. d) An X-ray examination
Answer: Major dental work. Rationale: The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work. This reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, I.V. line insertion, and X-rays do not contribute to the risk of infection.
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time? a) Medication therapy. b) Diet modification. c) Activity restrictions. d) Dental care.
Answer: Medication therapy. Rationale: Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown: Date:07/07/07 Time: 10:00 pm Progress Notes: The client is receiving D5W, 1,000 mL q 8 h. The NG tube is attached to low suction and draining well. The client has been NPO except ice chips. The client has had 10 mg morphine for pain at 6 a.m. E. Levine, RN What is most likely contributing to the client's abdominal distention? a) Nasogastric (NG) tube. b) Ice chips. c) I.V. fl uid intake. d) Morphine.
Answer: Morphine Rationale: The client is experiencing paralytic ileus. One of the adverse effects of morphine used to manage pain is decreased GI motility. Bowel manipulation and immobility also contribute to a postoperative ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice chips and I.V. fluids will not affect the ileus.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: a) Observe careful hand-washing procedures. b) Clean the incisional area with an antiseptic. c) Use prepackaged sterile dressings to cover the incision. d) Place soiled dressings in a waterproof bag before disposing of them.
Answer: Observe careful hand-washing procedures Rationale: Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial post-procedure nursing assessment for this client? a) Monitor the laboratory values. b) Observe neurologic function every 15 minutes. c) Observe the puncture site for swelling and bleeding. d) Monitor skin warmth and turgor.
Answer: Observe the puncture site for swelling and bleeding. Rationale: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? a) IV fluid solution. b) Pedal pulses. c) Nasal cannula flow rate. d) Capillary refill.
Answer: Pedal pulses Rationale: With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. I.V. fluids, nasal cannula setting, and capillary refill are important to assess, however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should: a) Position the client on a firm mattress. b) Keep the involved extremity warm with blankets. c) Position the left leg at or below the body's horizontal plane. d) Encourage the client to raise and lower his leg four times every hour.
Answer: Position the left leg at or below the body's horizontal plane. Rationale: Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard surface, such as a firm mattress, to avoid pressure ulcers. In addition, the involved extremity should be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery, which is contrary to the goal to promote arterial circulation
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? a) Prepare for transcutaneous pacing. b) Prepare to defibrillate the client at 200 joules. c) Administer an I.V. lidocaine infusion. d) Schedule the operating room for insertion of a permanent pacemaker.
Answer: Prepare for transcutaneous pacing. Rationale: Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third degree heart block. Transcutaneous pacing is used temporarily until a trans-venous or permanent pacemaker can be inserted.
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to: a) Maintain circulation. b) Manage pain. c) Prepare the client for emergency surgery. d) Teach postoperative breathing exercises.
Answer: Prepare the client for emergency surgery. Rationale: The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained, unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if ordered.
A client with a history of hypertension and peripheral vascular disease underwent an aorto-bifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2 ° C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/ hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse recommends that the primary care provider: a) Continues the pentoxifylline. b) Increases the I.V. fl uids. c) Restarts the metoprolol. d) Resumes the furosemide.
Answer: Restarts the metoprolol. Rationale: The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The potassium should also be assessed prior to starting the furosemide.
A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included: a) Chickenpox. b) Poliomyelitis. c) Rheumatic fever. d) Meningitis.
Answer: Rheumatic fever. Rationale: Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chickenpox, poliomyelitis, and meningitis are not associated with mitral stenosis.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: a) Showing the location of the obstruction and the collateral circulation. b) Scanning the affected extremity and identifying the areas of volume changes. c) Using ultrasound to estimate the velocity changes in the blood vessels. d) Determining how long the client can walk
Answer: Showing the location of the obstruction and the collateral circulation. Rationale: An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.
When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. a) Take and record daily pulse rate. b) Avoid air travel because of airport security alarms. c) Immobilize the affected arm for 4 to 6 weeks. d) Avoid using a microwave oven. e) Avoid lifting anything heavier than 3 lb.
Answer: Take and record daily pulse rate; Avoid lifting anything heavier than 3 lb. Rationale: The nurse must teach the client how to take and record his pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week post-insertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the physician. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.
A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has: a) Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days. b) Heart rate of 100 beats per minute after ambulating 200 feet. c) Urine output of 2,000 mL in 24 hours. d) Weakness and numbness in the lower extremities.
Answer: Weakness and numbness in the lower extremities. Rationale: One of the complications of a thoracoabdominal aneurysm repair is spinal cord injury. Therefore, it is important for the nurse to assess for signs and symptoms of neurologic changes at and below the site where the aneurysm was repaired. The client is expected to have moderate pain following surgery. An elevated heart rate is expected after physical exertion. It is important to monitor urine output following aneurysm surgery, but a urine output of 2,000 mL in 24 hours is adequate following surgery.
