ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 29 : Caring for Clients Undergoing Cardiovascular Surgery Questions
Question 1 of 5
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?
Correct Answer: B
Rationale: 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.
Question 2 of 5
The nurse is measuring central venous pressure readings for a client receiving fluid resuscitation. Prior to obtaining the reading, what nursing action is required?
Correct Answer: B
Rationale: 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 positioned 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.
Question 3 of 5
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?
Correct Answer: D
Rationale: 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.
Question 4 of 5
The nurse is caring for a client who 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?
Correct Answer: D
Rationale: 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, the nurse may notify either. Administration of medications without a physician's prescription is contraindicated.
Question 5 of 5
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 Knowledge Deficiency related to unfamiliarity with diagnostic tests, preoperative preparations, and postoperative care?
Correct Answer: A
Rationale: 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.