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 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?
Correct Answer: B
Rationale: 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. The other options are incorrect. The measurement of pulmonary artery pressure does not assess right-sided heart pressures or left atrial pressure.
Question 2 of 5
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?
Correct Answer: B
Rationale: 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.
Question 3 of 5
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?
Correct Answer: A
Rationale: 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.
Question 4 of 5
A client had a cardiac transplant 6 weeks ago. The client calls the clinic and informs the nurse he has a fever of $101^{\circ} \mathrm{F}$, chest tenderness, and flulike symptoms. What does the nurse suspect the client is experiencing?
Correct Answer: B
Rationale: 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.
Question 5 of 5
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?
Correct Answer: C
Rationale: 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 prescription.