HESI LPN ADN ENTRANCE EXAM MOBILITY / NCLEX - PN REVIEW -
CARDIOVASCULAR
Exams A Graded Verified Graded A Latest Version
the nurse is assigned to assist with caring for a client after cardiac
catheterization.
the nurse should plan to maintain bed rest for this client in which
position?
a) high-Fowler's position
b) lateral (side-lying) position
c) head elevation of 45 degrees
d) head elevation of no more than 30 degrees - ANSWER ..> d) head
elevated of no more than 30 degrees
rationale
after cardiac catheterization, the extremity into which the catheter was
inserted is kept straight for the prescribed time period.
the client may turn from side to side.
the client is placed in the supine position and the head of the bed is not
elevated to more than 30 degrees to keep the affected leg straight at
the grain and prevent arterial occlusion.
bathroom privileges are not allowed during the immediate
postcatheterization period.
for the high-fowler's position, the head of the bed is elevated 90
degrees.
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, a postcardiac surgery client with a blood urea nitrogen (BUN) level of
45 mg/dl and a serum creatinine level of 2.2 mg/dl has a total 2-hour
urine output of 25 ml.
the nurse understands that the client is at risk for which?
rationale
the client who undergoes cardiac surgery is at risk for acute kidney
injury from poor perfusion, hemolysis, low cardiac output, or
vasopressor medication therapy.
kidney injury is signaled by a decreased urine output and increased
BUN and creatinine levels.
the client may need medications to increase renal perfusion and could
need peritoneal dialysis or hemodialysis.
the nurse is preparing to ambulate a postoperative client after cardiac
surgery.
the nurse plans to do which to enable the client to best tolerate the
ambulation?
a) provide the client with a walker
b) remove the telemetry equipment
c) encourage the client to cough and deep breathe
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, d) premedicate the client with an analgesic before ambulating -
ANSWER ..> d) premedicate the client with an analgesic before
ambulating
rationale
the nurse should encourage regular use of pain medication for the first
48 to 72 hours after cardiac surgery, because analgesia will promote
rest, decrease myocardial oxygen consumption caused by pain, and
allow better participation in activities such as coughing, deep breathing
and ambulation.
a client is wearing a continuous cardiac monitor, which begins to alarm
at the nurse's station.
the nurse sees no electrocardiographic complexes on the screen.
the nurse should do which first?
a) call a code blue
b) call the HCP
c) check the client status and lead placement
d) press the recorder button the ECG console - ANSWER ..> c) check the
client status and lead placement
rationale
sudden loss of electrocardiographic complexes indicates ventricular
asystole or possibly electrode displacement.
checking of the client and equipment is the first action by the nurse.
the nurse in a medical unit is caring for a client with heart failure.
the client suddenly develops extreme dyspnea, tachycardia, and lung
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crackles, and the nurse suspects pulmonary edema.
, the nurse immediately notifies the RN and expects which interventions
to be prescribed?
select all that apply
administering oxygen
inserting a Foley catheter
administering forosemide (lasix)
administering morphine sulfate intravenously
transporting the client to the CCU
placing the client in a low-Fowler's side-lying position - ANSWER ..>
administering oxygen // inserting a Foley catheter // administering
furosemide (Lasix) // administering morphine sulfate intravenously
rationale
pulmonary edema is a life-threatening event that can result from
severe heart failure.
in pulmonary edema the left ventricle fails to eject sufficient blood, and
pressure increases in the lungs because of the accumulated blood.
oxygen is always prescribed, and the client is placed in a high-fowler's
position to ease the work of breathing.
Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid.
a foley catheter is inserted to accurately measure output.
intravenously administered morphine sulfate reduces venous return
(preload), decreases anxiety, and reduces the work of breathing.
transporting the client to the CCU is not a priority intervention.
in fact, this may not be necessary at all if the client's response to
treatment is successful.
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