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
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 2 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.
Question 3 of 5
The client is being prepared for cardiothoracic surgery and is very apprehensive. What medication can be administered with a physician's prescription to decrease the amount of anesthetic that the client will receive in surgery?
Correct Answer: B
Rationale: 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.
Question 4 of 5
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?
Correct Answer: D
Rationale: 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.
Question 5 of 5
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?
Correct Answer: A
Rationale: 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; don't 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.