A nurse is in charge of the coronary intensive care unit. Which ...

[dejastew]

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
 
  a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
  b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
  c. Client who is 1 day post percutaneous coronary intervention, going home this morning
  d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Question 2

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.

[kilada]

Answer to Question 1

ANS: B
Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

Answer to Question 2

ANS: D
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.

[dejastew]

Thanks for the timely response, appreciate it

[phuda]

TYSM