A client is scheduled for coronary artery bypass surgery (CABG) tomorrow morning and is currently receiving Nitroglycerin 20 mcg/minute IV. The client reports a new onset of chest pain with a severity of 6 on a 0 to 10 scale. After obtaining a STAT electrocardiogram and vital signs, what action would the nurse anticipate?

Discontinue the nitroglycerin drip.

Maintain the nitroglycerin drip at the same rate.

Administer sublingual nitroglycerin.

Titrate the nitroglycerin drip dose up.

Answer and Explanation

The Correct Answer is D

A. Discontinue the nitroglycerin drip: Stopping nitroglycerin abruptly can worsen myocardial ischemia by removing vasodilatory support. Discontinuation is not indicated for new-onset chest pain; rather, the infusion is typically adjusted to relieve angina while monitoring hemodynamic status.

B. Maintain the nitroglycerin drip at the same rate: Keeping the infusion at the current rate may be insufficient if the client is experiencing new chest pain. The purpose of IV nitroglycerin is to provide continuous antianginal effect, and dose adjustments are often necessary to address breakthrough symptoms.

C. Administer sublingual nitroglycerin: Sublingual nitroglycerin provides rapid relief of acute angina; however, for a client already on an IV infusion, the priority action is usually to titrate the IV rate to achieve continuous pain control while maintaining safe blood pressure. Sublingual administration may be considered if the infusion cannot be adjusted promptly.

D. Titrate the nitroglycerin drip dose up: Increasing the IV nitroglycerin rate is the appropriate intervention for breakthrough chest pain when vital signs are stable. Titration allows the nurse to optimize coronary vasodilation, reduce myocardial oxygen demand, and relieve angina, while continuously monitoring blood pressure and heart rate to prevent hypotension.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A vein in the leg was used to bypass the coronary artery: During CABG surgery, the saphenous vein from the leg is commonly harvested to create a graft that bypasses blocked coronary arteries. The leg dressing protects the incision site, prevents infection, and promotes healing after vein harvesting.

B. A filter is inserted in the leg to prevent embolization: Inferior vena cava (IVC) filters are sometimes placed to prevent pulmonary embolism, but this is unrelated to CABG surgery. There is no routine filter insertion in the leg during bypass surgery.

C. The arteries in the extremities are examined during surgery: Although vascular assessment may occur, the leg is not routinely opened for examination of arteries during CABG. The incision is specifically for vein harvesting rather than diagnostic assessment.

D. This is the access site for the heart-lung machine: The heart-lung machine typically connects via central vessels such as the aorta and right atrium, not through the leg. The leg incision is unrelated to cardiopulmonary bypass access.

A. I will limit lifting to 10 pounds for the next month. B. I will brush my teeth at least twice a day. C. I will expect to hear a clicking sound from my chest. D. I will stop taking apixaban after three months.

Correct Answer is D

Explanation

A. I will limit lifting to 10 pounds for the next month: Activity restrictions after valve replacement help prevent strain on the sternum and promote healing. Limiting heavy lifting for a defined period is appropriate and demonstrates understanding of post-operative precautions.

B. I will brush my teeth at least twice a day: Good oral hygiene is important to reduce the risk of infective endocarditis in clients with mechanical heart valves. Brushing teeth twice daily reflects proper preventive care and is encouraged.

C. I will expect to hear a clicking sound from my chest: Mechanical valves often produce an audible click due to the opening and closing of the prosthetic leaflets. Awareness of this sound prevents unnecessary anxiety and demonstrates correct patient education.

D. I will stop taking apixaban after three months: Mechanical mitral valve replacements require lifelong anticoagulation, typically with warfarin, to prevent thromboembolism. Stopping anticoagulation prematurely could lead to valve thrombosis or systemic emboli, indicating a misunderstanding that requires further education.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which explanation would the nurse give to the spouse of a client who had coronary artery bypass graft (CABG) surgery when asked why there is a dressing on the client's left leg?

Correct Answer is A

Explanation

The nurse is providing discharge education to a client status post mechanical mitral valve replacement. Which statement made by the client indicates the need for further education?

Correct Answer is D

Explanation

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which information is most important for the nurse to communicate to the provider before the procedure?

The nurse is caring for a client with a central venous pressure (CVP) monitoring line and is assessing right ventricular function and venous blood return. The results show a decreased central venous pressure. How does the nurse interpret the findings?

The nurse is caring for clients on a cardiac unit. Which client would the nurse assess first?

A nurse is caring for a client with the six second telemetry strip below. The nurse anticipates the emergency response team will administer which medication?

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse assesses a rapid and irregular heart rate with a significant pulse deficit. Which dysrhythmia does the nurse expect to find on the cardiac monitor?

The nurse is assessing a client who received a heart transplant 6 months ago for cardiomyopathy. What assessment finding would lead the nurse to suspect the transplant is being rejected?