the lpnlvn is caring for a client who has undergone a coronary artery bypass graft cabg surgery which action should the nurse take to prevent postoper
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Nursing Elites

ATI LPN

LPN Pharmacology Assessment A

1. The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?

Correct answer: A

Rationale: Encouraging the client to cough and deep breathe every 1 to 2 hours is crucial post-CABG surgery to prevent respiratory complications, such as atelectasis and pneumonia. These actions help to expand lung volume, clear secretions, and prevent the collapse of alveoli. Choices B, C, and D are incorrect because maintaining the client in a supine position at all times can lead to complications like decreased lung expansion, keeping the client on bed rest for the first 48 hours may increase the risk of thromboembolism, and restricting fluid intake postoperatively can lead to dehydration and electrolyte imbalances.

2. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

3. A client with heart failure is receiving digoxin. Which finding should indicate to the nurse that the client is experiencing digoxin toxicity?

Correct answer: C

Rationale: Bradycardia is a hallmark sign of digoxin toxicity. Digoxin, a medication used to treat heart conditions, can lead to toxicity manifesting as bradycardia. Bradycardia occurs due to the drug's effect on slowing down the heart rate excessively. Constipation (Choice A) is not typically associated with digoxin toxicity. Blurred vision (Choice B) is more commonly linked to visual disturbances caused by digoxin, but it is not a defining sign of toxicity. Dry cough (Choice D) is not a recognized symptom of digoxin toxicity. It is crucial for the nurse to recognize the early signs of digoxin toxicity to prevent serious complications and provide appropriate interventions promptly.

4. What is the initial action the nurse should take for a client who had a myocardial infarction (MI) and is experiencing restlessness, agitation, and an increased respiratory rate?

Correct answer: A

Rationale: Administering oxygen is the priority action for a client experiencing restlessness, agitation, and an increased respiratory rate after a myocardial infarction (MI). This intervention helps ensure adequate oxygenation, improve cardiac function, and reduce the workload on the heart. Oxygen therapy takes precedence over administering medications like morphine sulfate or notifying the healthcare provider as it addresses the immediate need for oxygenation. Checking the blood pressure is also important but not as urgent as ensuring proper oxygen supply.

5. The client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?

Correct answer: B

Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor the effectiveness of anticoagulant therapy, especially with heparin. A prolonged aPTT indicates effective anticoagulation, reducing the risk of further clot formation in the client with deep vein thrombosis (DVT). The other options, such as complete blood count (CBC), serum electrolytes, and liver function tests, do not directly assess the therapeutic effectiveness of anticoagulant therapy. Therefore, the correct answer is B.

Similar Questions

The healthcare provider is caring for a client with hypertension who is receiving a beta blocker. The provider should monitor for which potential side effect?
The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?
A client has a new prescription for transdermal nitroglycerin patches. Which of the following instructions should be included for proper use?
A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?
The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?

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