ATI Targeted Medical-Surgical 2019: Cardiovascular Exam

A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me because I haven't taken my aspiring in a week." b. "My blood pressure shouldn't be high because I took my BP medication this morning." c. "I took my warfarin last night according to my usually schedule." d. "I will check my BP because I took a reduced dose of insulin this morning." - ANSWER-C: "I took my warfarin last night according to my usually schedule." Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding. A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Administering IV morphine sulfate B. Administering oxygen at 2:/min via nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy - ANSWER-D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dl b. History of peripheral arterial disease. c. Urine output 200 ml/4 hr. D. Previous allergic reaction to shellfish - ANSWER-D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure. A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain clients current weight B. Review serum electrolyte values