Cardiovascular Saunders
1. The nurse is caring for a client who is on strict bed rest and creates a
plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing
action is most helpful in preventing these disorders from developing?
A. Restricting fluids
B. Placing a a pillow under the knees
C. Encouraging active range of motion
D. Applying heating pads to the lower extremities: C. Encouraging active range of motion
Rationale:
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immo- bilized clients. Basic preventive
measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf
compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under th
knees may cause venous stasis. Heat would not be applied without a primary health care provider's prescription.
2. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for
cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for
48 hours after the procedure?
A. Glipozide
B. Metformin
C. Repaglinide
D. Regular Insulin: B. Metformin
Rationale:
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of
contrast medium during the procedure. Metformin is excreted by the kidneys. If the contrast medium affects kidney
function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the
remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization. Repaglinide is
metabolized by the liver and excreted in bile. Glipizide is eliminated primarily by hepatic biotransformation.
, Cardiovascular Saunders
3. A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output
for the
, Cardiovascular Saunders
ubsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16
mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse
would anticipate that the client is at risk for which problem?
A. Hypovolemia
B. Acute kidney injury
C. Glomerulonephritis
D. Urinary tract infection: B. Acute kidney injury
Rationale:
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or
vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen
(BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male
0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female
0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need
peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or
urinary tract infection.
4. The nurse is caring for a client who has just had implantation of an auto- matic internal cardioverter-
defibrillator. The nurse would assess which item based on priority?
A. Anxiety level of the client and family
B. Presence of a Medic Alert card for the client to carry
C. Knowledge of restrictions on post discharge physical activity
D. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver: D.
Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
Rationale:
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device
settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is
activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The
, Cardiovascular Saunders
remaining options are also nursing interventions but are not the priority.
1. The nurse is caring for a client who is on strict bed rest and creates a
plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing
action is most helpful in preventing these disorders from developing?
A. Restricting fluids
B. Placing a a pillow under the knees
C. Encouraging active range of motion
D. Applying heating pads to the lower extremities: C. Encouraging active range of motion
Rationale:
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immo- bilized clients. Basic preventive
measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf
compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under th
knees may cause venous stasis. Heat would not be applied without a primary health care provider's prescription.
2. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for
cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for
48 hours after the procedure?
A. Glipozide
B. Metformin
C. Repaglinide
D. Regular Insulin: B. Metformin
Rationale:
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of
contrast medium during the procedure. Metformin is excreted by the kidneys. If the contrast medium affects kidney
function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the
remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization. Repaglinide is
metabolized by the liver and excreted in bile. Glipizide is eliminated primarily by hepatic biotransformation.
, Cardiovascular Saunders
3. A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output
for the
, Cardiovascular Saunders
ubsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16
mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse
would anticipate that the client is at risk for which problem?
A. Hypovolemia
B. Acute kidney injury
C. Glomerulonephritis
D. Urinary tract infection: B. Acute kidney injury
Rationale:
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or
vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen
(BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male
0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female
0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need
peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or
urinary tract infection.
4. The nurse is caring for a client who has just had implantation of an auto- matic internal cardioverter-
defibrillator. The nurse would assess which item based on priority?
A. Anxiety level of the client and family
B. Presence of a Medic Alert card for the client to carry
C. Knowledge of restrictions on post discharge physical activity
D. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver: D.
Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
Rationale:
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device
settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is
activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The
, Cardiovascular Saunders
remaining options are also nursing interventions but are not the priority.
