MS Ch 28 & 29

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?

"The heart has to be transplanted within 6 hours, so it is advisable that you go to the hospital to be prepared now."

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?

Aids in early treatment of fluid imbalances

A client will be placed on cardiopulmonary bypass for a mitral valve replacement. What type of medication will be required for this client?

An anticoagulant

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?

An anxiolytic drug

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?

Assist the client to splint with a pillow when coughing and deep breathing.

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?

Cardiac tamponade

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?

Client and family will understand the purpose, preparation, and aftercare of tests and surgery.

A client is diagnosed with obstructive atherosclerotic plaque of the left carotid artery. What procedure does the nurse anticipate preparing the client for?

Endaterectomy

The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?

Experiences exertional dyspnea when waling 3 feet states, "I cannot catch my breath."

You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

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?

Hyperoxygenate the client with 100% oxygen

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?

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.

The nurse instructs the client with heart failure to weight themselves at the same time each day using the same scale. When should the client contact the physician?

If the weight gain is more than 2 lbs in 24 hrs

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?

Low-sodium diet

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?

Many older adults have other things wrong with them besides their cardiac problems

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?

Morphine sulfate

The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?

Offer small, frequent feedings

A client is taking furosemide (Lasix) for the treatment of heart failure. What food should the nurse suggest that is rich in potassium?

Peanut butter

The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?

Potassium level of 3.1

The nurse is preparing a client for coronary artery bypass surgery. What vessel does the nurse know is most commonly used for grafting?

Saphenous vein

A client with heart failure informs the nurse he has not had a bowel movement in 2 days. Why would it be important for the nurse to obtain an order for a stool softener?

Straining causes the valsalva maneuver, which can cause dangerous effects

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?

The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the blood pressure and oxygen saturation.

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?

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.

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are more difficult to remove

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?

The client will require anticoagulation

The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?

The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at intermittent times during the 45-minute test. The client need not to drink plenty of fluids, avoid activities before or after the test, or avoid dairy products during the test.

The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?

There is excess fluid volume in the interstitial space in areas affected by gravity

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?

To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.

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?

To relieve the client's insecurity and anxiety

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?

Use a doppler ultrasound device

The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated patient to help the nurse evaluate the client's response to diuretics?

Use a urinary catheter

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the meds and notify the physician of the HR