DETAILED ANSWERS|LATEST
A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is
on an intravenous infusion of heparin. The client's spouse asks why the client needs this
medication. What response by the nurse is best?
a. "The t-PA didn't dissolve the entire coronary clot."
b. "The heparin keeps that artery from getting blocked again."
c. "Heparin keeps the blood as thin as possible for a longer time."
d. "The heparin prevents a stroke from occurring as the t-PA wears off." -
ANSWER ANS: B After the original intracoronary clot has dissolved, large amounts of
thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding.
The other statements are not accurate. Heparin is not a "blood thinner," although laypeople
may refer to it as such
PHARMOCOLOGICAL AND PARENTAL THERAPIES
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges.
The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%,
pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action
by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan - ANSWER ANS: B This client's physiologic
parameters did not exceed normal during and after activity, so it is safe for the client to
continue using the bathroom. There is no indication that the client needs oxygen, a
commode, or a bedpan.
REDUCTION OF RISK
1
,A nurse is caring for a client who had a myocardial infarction. The nurse is confused because
the client states that nothing is wrong and yet listens attentively while the nurse provides
education on lifestyle changes and healthy menu choices. What response by the charge
nurse is best?
a. "Continue to educate the client on possible healthy changes."
b. "Emphasize complications that can occur with noncompliance."
c. "Tell the client that denial is normal and will soon go away."
d. "You need to make sure the client understands this illness." - ANSWER ANS: A
Clients are often in denial after a coronary event. The client who seems to be in denial but is
compliant with treatment may be using a healthy form of coping that allows time to process
the event and start to use problem-focused coping. The nurse would not discourage this
type of denial and coping, but rather continue providing education in a positive manner.
Emphasizing complications may make the client defensive and more anxious. Telling the
client that denial is normal is placing too much attention on the process. Forcing the client to
verbalize understanding of the illness is also potentially threatening to the client.
PSYCHOSOCIAL INTEGRITY
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution
does the nurse implement for this client?
a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position. - ANSWER ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse
would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP
readings and assessing trends are important nursing actions related to
hemodynamic monitoring, but are not specifically related to safety. The client does not have
to be NPO while undergoing
hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring
SAFTEY INFECTION CONTROL
2
, A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse
notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood
pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is
most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain. - ANSWER ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from
the insertion site. Since these vital signs are out of the normal range, are a change, and are
consistent with blood loss, the nurse would assess the client for any bleeding associated
with the arterial line. The nurse would document the findings after a full assessment. The
client may or may not need pain medication and rest; the nurse first needs to rule out any
emergent bleeding.
REDUCTION OF RISK
A client is in the preoperative holding area prior to an emergency coronary artery bypass
graft (CABG). The client is yelling at family members and tells the doctor to "just get this over
with" when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client's stress levels.
d. Tell the client that anxiety is common and that you can help - ANSWER ANS: D
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent
situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear
is common and offer to help. The other actions will not reduce the client's anxiety
PSYCHOSOCIAL INTEGRITY
A client is in the clinic a month after having a myocardial infarction. The client reports
sleeping well since moving into the guest bedroom. What response by the nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
3
A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is
on an intravenous infusion of heparin. The client's spouse asks why the client needs this
medication. What response by the nurse is best?
a. "The t-PA didn't dissolve the entire coronary clot."
b. "The heparin keeps that artery from getting blocked again."
c. "Heparin keeps the blood as thin as possible for a longer time."
d. "The heparin prevents a stroke from occurring as the t-PA wears off." -
ANSWER ANS: B After the original intracoronary clot has dissolved, large amounts of
thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding.
The other statements are not accurate. Heparin is not a "blood thinner," although laypeople
may refer to it as such
PHARMOCOLOGICAL AND PARENTAL THERAPIES
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges.
The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%,
pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action
by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan - ANSWER ANS: B This client's physiologic
parameters did not exceed normal during and after activity, so it is safe for the client to
continue using the bathroom. There is no indication that the client needs oxygen, a
commode, or a bedpan.
REDUCTION OF RISK
1
,A nurse is caring for a client who had a myocardial infarction. The nurse is confused because
the client states that nothing is wrong and yet listens attentively while the nurse provides
education on lifestyle changes and healthy menu choices. What response by the charge
nurse is best?
a. "Continue to educate the client on possible healthy changes."
b. "Emphasize complications that can occur with noncompliance."
c. "Tell the client that denial is normal and will soon go away."
d. "You need to make sure the client understands this illness." - ANSWER ANS: A
Clients are often in denial after a coronary event. The client who seems to be in denial but is
compliant with treatment may be using a healthy form of coping that allows time to process
the event and start to use problem-focused coping. The nurse would not discourage this
type of denial and coping, but rather continue providing education in a positive manner.
Emphasizing complications may make the client defensive and more anxious. Telling the
client that denial is normal is placing too much attention on the process. Forcing the client to
verbalize understanding of the illness is also potentially threatening to the client.
PSYCHOSOCIAL INTEGRITY
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution
does the nurse implement for this client?
a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position. - ANSWER ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse
would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP
readings and assessing trends are important nursing actions related to
hemodynamic monitoring, but are not specifically related to safety. The client does not have
to be NPO while undergoing
hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring
SAFTEY INFECTION CONTROL
2
, A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse
notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood
pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is
most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain. - ANSWER ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from
the insertion site. Since these vital signs are out of the normal range, are a change, and are
consistent with blood loss, the nurse would assess the client for any bleeding associated
with the arterial line. The nurse would document the findings after a full assessment. The
client may or may not need pain medication and rest; the nurse first needs to rule out any
emergent bleeding.
REDUCTION OF RISK
A client is in the preoperative holding area prior to an emergency coronary artery bypass
graft (CABG). The client is yelling at family members and tells the doctor to "just get this over
with" when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client's stress levels.
d. Tell the client that anxiety is common and that you can help - ANSWER ANS: D
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent
situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear
is common and offer to help. The other actions will not reduce the client's anxiety
PSYCHOSOCIAL INTEGRITY
A client is in the clinic a month after having a myocardial infarction. The client reports
sleeping well since moving into the guest bedroom. What response by the nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
3
