Question

A nurse is assisting with the care of a client 2 hr. postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Check the client's distal pulses in both legs.

Rationale :

🟦 After cardiac catheterization (often via femoral artery), the priority is assessing for vascular compromise distal to the insertion site.

🟦 Checking distal pulses confirms adequate arterial blood flow and helps detect complications like arterial occlusion, thrombosis, or embolus early.

🟦 Weak/absent pulses, cool extremity, delayed cap refill, or pallor can indicate impaired perfusion requiring rapid intervention.

🟦 This assessment also supports early recognition of bleeding-related complications that can reduce circulation, especially if a hematoma compresses vessels.

🟦 Neurovascular checks are time-sensitive in the first hours post-procedure because vascular changes can progress quickly to limb ischemia.

Restrict the client's oral fluids.

🟦 Fluids are commonly encouraged (if not contraindicated) to help flush contrast dye and protect kidney function.

🟦 Restricting fluids can contribute to dehydration and does not prevent common cath complications.

Keep the client overnight.

🟦 Overnight stay depends on procedure type and patient stability, not a routine nursing action at 2 hours post-op.

🟦 Immediate priorities are assessment and complication prevention, not disposition decisions.

Keep the client on bed rest for 12 hr.

🟦 Bed rest duration varies by access site and closure device; 12 hours is not universally required.

🟦 The immediate nursing priority is vascular assessment, especially distal pulses and insertion site checks.

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Answer 2

Correct Answers:

Dull, aching calf pain

Rationale :

🟣 A thrombus (often DVT) commonly presents with unilateral calf pain described as dull, aching, and persistent.

🟣 Postoperative vascular clients are at higher risk due to immobility, vessel manipulation, and hypercoagulability.

🟣 Calf pain suggests impaired venous return and inflammation from clot formation in deep veins.

🟣 The nurse should also watch for associated findings like swelling, warmth, and tenderness, but pain is a key early sign.

🟣 Identifying thrombus early helps prevent pulmonary embolism, which can become rapidly fatal if the clot dislodges.

Positive Kernig's sign

🟣 Kernig’s sign is associated with meningeal irritation (e.g., meningitis), not venous thrombosis.

🟣 It is unrelated to postoperative vascular thrombus assessment.

Positive Homan's sign

🟣 Homan’s sign is not a reliable indicator and is no longer recommended as a diagnostic finding for DVT.

🟣 For safety, nurses prioritize symptoms like calf pain/swelling and diagnostic studies.

Soft, pliable calf muscle

🟣 A soft, pliable calf suggests normal tissue tone and does not indicate clot formation.

🟣 Thrombus is more consistent with tenderness, swelling, and discomfort.

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Answer 3

Correct Answers:

"A small catheter with a balloon is threaded into a vessel in the groin."

Rationale :

🟢 Balloon valvuloplasty is a minimally invasive procedure where a catheter is inserted through a large vessel—commonly the femoral artery/vein in the groin.

🟢 The balloon is positioned across a narrowed valve and inflated to widen the valve opening, improving forward blood flow.

🟢 Teaching should emphasize that the procedure is catheter-based, not open surgery, which reduces recovery time compared with valve replacement.

🟢 It is often used for stenotic valves when surgery is high risk or as a bridge to definitive repair.

🟢 Explaining groin access prepares the client for post-procedure care like monitoring the puncture site for bleeding and checking distal pulses.

“The balloon is inflated to remove the valve and insert a prosthetic ring.”

🟢 Balloon valvuloplasty does not remove the valve or insert prosthetic material.

🟢 It temporarily widens a narrowed valve by stretching it open.

“The procedure involves replacing the diseased valve with a new one.”

🟢 Valve replacement is a different procedure (surgical or transcatheter replacement), not balloon valvuloplasty.

🟢 Valvuloplasty is a dilation technique, not replacement.

“This procedure can only be performed on the aortic valve.”

🟢 Balloon valvuloplasty can be performed on other valves (e.g., mitral) depending on the condition.

🟢 It is not limited exclusively to the aortic valve.

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Answer 4

Correct Answers:

The client reports dizziness when ambulating to the bathroom.

Rationale :

🟠 Dizziness with ambulation suggests possible orthostatic hypotension, which can be worsened by antihypertensive medications.

🟠 The nurse should assess blood pressure lying/sitting/standing and evaluate fall risk before administering the dose.

🟠 Giving the medication without further assessment could lead to syncope, falls, and injury.

🟠 This symptom can also indicate excessive medication effect, dehydration, or underlying cardiac issues affecting perfusion.

🟠 Clinical judgment requires collecting more data because antihypertensives lower BP and may compromise safety if the client is already symptomatic.

Trouble sleeping

🟠 Sleep difficulty does not directly indicate unsafe blood pressure status for medication administration.

🟠 It is not an immediate contraindication to giving an antihypertensive.

Ate 60% of breakfast

🟠 Partial meal intake does not usually affect antihypertensive safety unless the medication specifically requires food.

🟠 The priority concern is perfusion symptoms like dizziness, not appetite.

Urine output 400 mL in 8 hr

🟠 This output is generally acceptable for many adults and does not automatically indicate instability.

🟠 Dizziness is a stronger cue for possible hypotension requiring immediate assessment.

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Answer 5

Correct Answers:

2

Rationale :

✍️Formula

🟡 Tablets = Ordered dose ÷ Dose per tablet

🟡 Tablets = 650 mg ÷ 325 mg

👉 2

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Answer 6

Correct Answers:

Have protamine available in case of overdose.

Rationale :

🔴 Enoxaparin is a low–molecular-weight heparin that increases bleeding risk, so overdose requires a reversal plan.

🔴 Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin products, including partial reversal for enoxaparin.

🔴 Teaching this supports safe practice by preparing the nurse to respond quickly if major bleeding occurs.

🔴 This is especially important because enoxaparin is a high-alert medication, and adverse bleeding can escalate rapidly.

🔴 Keeping the antidote available is a safety standard when administering anticoagulants in higher-risk clients.

Monitor potassium level

🔴 Routine teaching for enoxaparin focuses more on bleeding monitoring and injection technique than potassium.

🔴 Potassium monitoring is not the primary standard instruction for typical enoxaparin administration teaching.

Administer into a large muscle

🔴 Enoxaparin is administered subcutaneously, not intramuscularly, to prevent tissue bleeding and hematoma.

🔴 IM injection increases risk of bleeding and is unsafe for anticoagulated clients.

Expel air bubble prior to administration

🔴 Prefilled enoxaparin syringes usually keep the air bubble to ensure full dose delivery and reduce bruising.

🔴 Expelling it can lead to dose loss and does not align with standard LMWH administration guidance.

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Answer 7

Correct Answers:

Educate Sarah on maintaining meticulous oral hygiene and scheduling regular dental check-ups to minimize the risk of bacteremia
Instruct Sarah and her family about the necessity of prophylactic antibiotics before any invasive dental or surgical procedures in the future.

Rationale :

Educate Sarah on maintaining meticulous oral hygiene and scheduling regular dental check-ups to minimize the risk of bacteremia

🟦 Infective endocarditis can recur when bacteria enter the bloodstream and attach to susceptible cardiac tissue, so reducing sources of bacteremia is a priority.

🟦 The mouth is a common entry point because inflamed gums and dental infections allow bacteria to enter circulation during brushing, flossing, or dental work.

🟦 Teaching meticulous oral care helps prevent gingivitis and periodontal disease, which lowers bacterial load and reduces the chance of bloodstream invasion.

🟦 Regular dental check-ups help identify and treat oral infections early, preventing them from becoming a persistent bacteremia source.

🟦 This teaching is essential because consistent oral hygiene is a long-term preventive measure that directly targets one of the most frequent triggers of endocarditis relapse.

Instruct Sarah and her family about the necessity of prophylactic antibiotics before any invasive dental or surgical procedures in the future

🟦 Invasive dental and certain surgical procedures can cause transient bacteremia, which can seed the heart and trigger recurrence in high-risk clients.

🟦 Prophylactic antibiotics reduce bacterial burden in the bloodstream during procedures that disrupt mucosal surfaces and tissues.

🟦 Teaching the family ensures they inform providers of Sarah’s endocarditis history so prophylaxis is not missed.

🟦 This intervention helps prevent serious complications such as valvular damage, systemic emboli, and repeat prolonged hospitalization.

🟦 Prophylaxis education also promotes long-term safety because Sarah will likely need this precaution repeatedly throughout adolescence and adulthood with future procedures.

Recommend that Sarah immediately discontinue antibiotics once symptoms improve to prevent antibiotic resistance

🟦Endocarditis requires completing the full prescribed antibiotic course because symptoms can improve before the infection is fully eradicated.

🟦Stopping early increases risk of relapse, persistent infection, and resistant organisms because surviving bacteria may regrow and become harder to treat.

Explain to Sarah that future fevers and chills are normal and do not require medical attention

🟦Fever and chills can be early signs of recurrence or complications and must be evaluated promptly.

🟦Teaching a child to ignore these symptoms delays treatment and increases risk of serious outcomes like sepsis or worsening valve injury.

Instruct Sarah that no further follow-up appointments are needed after completing antibiotic therapy

🟦Follow-up is critical to monitor recovery, assess for complications, and confirm infection resolution through clinical evaluation and sometimes lab/imaging review.

🟦Skipping follow-up increases the risk of missing late complications such as valvular dysfunction, ongoing bacteremia, or recurrence.

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Answer 8

Correct Answers:

Subcutaneous nodules over bony prominences
Polyarthritis affecting multiple joints
Cardiac murmur indicating valvular damage

Rationale :

Subcutaneous nodules over bony prominences

🟦 Subcutaneous nodules are a classic finding of acute rheumatic fever, which can progress to rheumatic heart disease after a recent streptococcal throat infection.

🟦 These nodules are typically firm, painless, and attached to tendons or bony prominences, reflecting an inflammatory immune response.

🟦 Their presence supports that the body is reacting to strep through molecular mimicry, where antibodies cross-react with human tissues.

🟦 Nodules are strongly associated with carditis, so they raise concern for cardiac involvement even before severe symptoms appear.

🟦 Assessing for nodules helps the nurse identify systemic disease activity and strengthens suspicion that the current presentation is post-strep rheumatic disease.

Polyarthritis affecting multiple joints

🟦 Migratory polyarthritis is one of the most common manifestations of acute rheumatic fever and is strongly linked to recent Group A strep infection.

🟦 The pain typically involves large joints (knees, ankles, elbows, wrists) and may move from one joint to another.

🟦 This pattern supports an immune-mediated inflammatory process rather than localized trauma or overuse injury.

🟦 Joint inflammation often occurs along with fever and systemic symptoms, matching the patient’s complaint of joint pain and fever.

🟦 Identifying polyarthritis is important because it helps confirm the clinical picture and prompts timely management to prevent long-term valvular damage.

Cardiac murmur indicating valvular damage

🟦 A new cardiac murmur supports suspicion of rheumatic heart disease because rheumatic fever can cause carditis and damage heart valves.

🟦 The most commonly affected valve is the mitral valve, which can lead to regurgitation that is heard as a murmur.

🟦 Chest discomfort combined with a murmur raises concern for active cardiac inflammation and evolving valvular dysfunction.

🟦 Early detection matters because untreated inflammation can result in chronic scarring, leading to stenosis or regurgitation later in life.

🟦 Assessing for murmurs helps identify complications early and supports immediate referral for further evaluation (e.g., echocardiography).

Increased urine output

🟦Increased urine output is not a typical feature used to support rheumatic fever or rheumatic heart disease suspicion.

🟦Rheumatic disease primarily affects joints, heart, and sometimes skin/neurologic function, not urinary volume patterns.

Cough with green sputum

🟦Green sputum suggests a respiratory infection such as bronchitis or pneumonia rather than a post-strep immune complication.

🟦Rheumatic heart disease is driven by immune response and valvular inflammation, not purulent sputum production.

Night sweats

🟦Night sweats are nonspecific and more commonly associated with chronic infections (e.g., tuberculosis), malignancy, or systemic illness.

🟦They are not a classic hallmark sign used to confirm rheumatic heart disease following strep throat.

Elevated blood glucose levels

🟦Elevated glucose points to metabolic/endocrine issues (e.g., diabetes), not rheumatic fever mechanisms.

🟦It does not support the post-strep inflammatory pattern affecting joints and valves.

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Answer 9

Correct Answers:

Comparing the temperature of the affected limb to the unaffected limb by using the back of the hand to feel for temperature differences.

Rationale :

🧊 Poikilothermia means the affected extremity becomes cool and reflects reduced perfusion rather than maintaining normal warmth.

🧊 The correct technique is bilateral comparison because the unaffected limb provides the best “normal” baseline for that patient.

🧊 Using the back of the hand improves sensitivity to temperature changes and helps detect subtle cooling early.

🧊 A cooler limb under a cast can signal vascular compromise from swelling, tight cast pressure, or evolving compartment syndrome.

🧊 Early identification allows rapid interventions to prevent ischemia, nerve injury, and tissue necrosis.

Asking the patient if they feel numbness or tingling

🧊 Numbness/tingling assesses paresthesia, not temperature change.

🧊 It reflects nerve compression, which is different from poikilothermia.

Checking for changes in skin color such as pallor or cyanosis

🧊 Color changes assess pallor/cyanosis, not limb temperature.

🧊 They are important neurovascular checks but not the assessment technique for poikilothermia.

Assessing the pulse strength distal to the injury

🧊 Distal pulses assess blood flow, not temperature specifically.

🧊 Poikilothermia requires temperature comparison, even if pulses are present.

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Answer 10

Correct Answers:

Taking the blood pressure within 10 minutes following nicotine or caffeine ingestion

Rationale :

🩺 Nicotine and caffeine can cause vasoconstriction and transient BP elevation, producing falsely high readings.

🩺 Measuring too soon after ingestion reduces accuracy and may lead to inappropriate medication changes or misclassification of hypertension severity.

🩺 Best practice includes avoiding nicotine/caffeine for at least 30 minutes before measurement when possible, and ensuring a standardized technique.

🩺 Accurate BP data is essential because hypertension management decisions depend on reliable trends, not single skewed readings.

🩺 Avoiding this error improves diagnostic precision and supports safe clinical judgment.

Seating the client with arm supported at heart level

🩺 This is the correct positioning and improves accuracy by preventing hydrostatic pressure errors.

🩺 Unsupported arms can artificially raise readings, so support is recommended.

Using a cuff encircling at least 80% of the limb

🩺 Proper cuff sizing is essential; a cuff that fits ≥80% improves measurement validity.

🩺 Too small a cuff falsely elevates BP, so correct sizing is recommended.

Measuring after the client sits quietly for 5 minutes

🩺 Resting 5 minutes is a standard step that reduces stress-related BP spikes.

🩺 Skipping rest increases variability and reduces accuracy.

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Custom MS 1 Exam 4 Ch 21 23 Group B Nov May

No.

1 :
A nurse is assisting with the care of a client 2 hr. postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

3 :
A nurse is reinforcing preoperative teaching with a client who is scheduled for a balloon valvuloplasty. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

5 :
A nurse is preparing to administer aspirin 650 mg PO. Available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) tablet(s)

6 :
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is assessing Mr. Lewis, who has a newly applied cast on his left leg after a fracture, During the neurovascular assessment, the nurse suspects poikilothermia. Which action best demonstrates the correct assessment technique for poikilothermia in this patient?

10 :
A nurse is checking the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following:

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Custom MS 1 Exam 4 Ch 21 23 Group B Nov May

No.

1 : A nurse is assisting with the care of a client 2 hr. postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

2 : A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

3 : A nurse is reinforcing preoperative teaching with a client who is scheduled for a balloon valvuloplasty. Which of the following statements should the nurse include in the teaching?

4 : A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

5 : A nurse is preparing to administer aspirin 650 mg PO. Available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) tablet(s)

6 : A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

9 : A nurse is assessing Mr. Lewis, who has a newly applied cast on his left leg after a fracture, During the neurovascular assessment, the nurse suspects poikilothermia. Which action best demonstrates the correct assessment technique for poikilothermia in this patient?

10 : A nurse is checking the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following:

1 :
A nurse is assisting with the care of a client 2 hr. postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

3 :
A nurse is reinforcing preoperative teaching with a client who is scheduled for a balloon valvuloplasty. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

5 :
A nurse is preparing to administer aspirin 650 mg PO. Available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) tablet(s)

6 :
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is assessing Mr. Lewis, who has a newly applied cast on his left leg after a fracture, During the neurovascular assessment, the nurse suspects poikilothermia. Which action best demonstrates the correct assessment technique for poikilothermia in this patient?

10 :
A nurse is checking the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following: