a nurse is providing discharge teaching to a client following a heart transplant which of the following information should the nurse include in the te

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

A. Immunosuppressant medications need to be taken for up to 1 year
B. Shortness of breath might be an indication of transplant rejection
C. The surgical site will heal in 3 to 4 weeks after surgery
D. Begin 45 minutes of moderate aerobic exercise per day following discharge

Correct answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

2. What ECG change is associated with hyperkalemia?

A. Flattened T waves
B. ST depression
C. Prominent U waves
D. Elevated ST segments

Correct answer: B

Rationale: The correct ECG change associated with hyperkalemia is ST depression. Hyperkalemia typically presents with ECG changes such as peaked T waves, prolonged PR interval, widened QRS complex, and finally, ST segment depression. Flattened T waves are more commonly associated with hypokalemia. Prominent U waves are seen in hypokalemia as well. Elevated ST segments are not a typical ECG finding in hyperkalemia.

3. What are the signs and symptoms of a hemorrhagic stroke?

A. Sudden severe headache, decreased level of consciousness, and seizures
B. Loss of consciousness and weakness
C. Temporary vision loss
D. Severe chest pain and shortness of breath

Correct answer: A

Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.

4. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

A. Increase the flow of the enema
B. Lower the height of the enema solution container
C. Stop the enema procedure
D. Remove the enema tubing

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

5. What teaching should be provided after cataract surgery?

A. Avoid NSAIDs
B. Wear dark glasses outdoors
C. Creamy white drainage is normal
D. Avoid bright lights

Correct answer: A

Rationale: The correct teaching that should be provided after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to prevent bleeding, especially in the eye area. While wearing dark glasses outdoors is important to protect the eyes, it is not the most critical teaching after cataract surgery. Creamy white drainage being normal is not relevant to post-cataract surgery teaching. Avoiding bright lights is generally recommended for patients with certain eye conditions but is not a specific teaching point after cataract surgery.