CMSRN - Medical-Surgical Nursing Cardiovascular and Hematological Care Questions and Answers — Questions and Answers
Question 1: A nurse is creating a discharge plan for a 68-year-old patient who underwent a coronary artery bypass graft (CABG). Which instruction is most important to include to prevent complications related to the sternotomy?
- "You can resume driving as soon as you feel you are no longer taking opioid pain medication."
- "Use a pillow to splint your chest when you cough or take deep breaths." (Correct answer)
- "It is acceptable to lift objects up to 20 pounds for the first 2 weeks."
- "Take a full bath daily to keep the incision clean."
Correct answer: "Use a pillow to splint your chest when you cough or take deep breaths."
Splinting the chest incision with a pillow provides support to the sternum, reduces pain, and helps maintain the integrity of the surgical site during activities that increase intrathoracic pressure, such as coughing and deep breathing. This is a crucial intervention to prevent sternal dehiscence. Patients should avoid lifting objects heavier than 5-10 pounds, driving for about 4-6 weeks, and taking baths until the incision is fully healed to prevent infection and strain on the sternum.
Question 2: A patient with a history of atrial fibrillation is being treated with warfarin. The nurse reviews the patient's morning labs and notes an INR of 4.5. The patient has no active bleeding. Which of the following is the nurse's priority action?
- Administer the next scheduled dose of warfarin.
- Prepare to administer protamine sulfate.
- Notify the healthcare provider and hold the next dose of warfarin. (Correct answer)
- Instruct the patient to increase their intake of leafy green vegetables.
Correct answer: Notify the healthcare provider and hold the next dose of warfarin.
An INR of 4.5 is supratherapeutic (target is typically 2.0-3.0 for atrial fibrillation), which places the patient at a significant risk for bleeding. The priority action is to hold the next dose of warfarin to prevent the INR from rising further and to notify the provider for further orders, which may include a dose adjustment or administration of Vitamin K. Protamine sulfate is the antidote for heparin, not warfarin. Instructing the patient to alter their diet is not the immediate priority, and administering the scheduled dose would be unsafe.
Question 3: A medical-surgical nurse is caring for a patient admitted with an acute exacerbation of heart failure. Which of the following nursing diagnoses is the highest priority?
- Activity Intolerance related to fatigue and dyspnea.
- Anxiety related to breathlessness and fear of death.
- Knowledge Deficit related to the disease process and self-care.
- Excess Fluid Volume related to compromised regulatory mechanisms. (Correct answer)
Correct answer: Excess Fluid Volume related to compromised regulatory mechanisms.
During an acute exacerbation of heart failure, excess fluid volume is the priority problem as it leads to pulmonary congestion, impaired gas exchange, and respiratory distress. Addressing the fluid overload through interventions like diuretic administration and fluid restriction is critical to stabilize the patient's cardiopulmonary status. While the other nursing diagnoses are relevant, they are secondary to the immediate life-threatening issue of fluid volume excess.
Question 4: A 24-year-old patient is admitted to the medical-surgical unit in a sickle cell vaso-occlusive crisis. The patient is reporting severe pain (10/10) in their extremities and back. Which of the following interventions is the highest priority for the nurse to implement?
- Applying cold compresses to painful joints.
- Administering intravenous fluids. (Correct answer)
- Encouraging frequent ambulation to promote circulation.
- Administering prophylactic antibiotics.
Correct answer: Administering intravenous fluids.
During a vaso-occlusive crisis, sickled red blood cells clump together, obstructing blood flow and causing severe pain and tissue ischemia. Intravenous hydration is a priority intervention as it helps to increase blood volume, reduce blood viscosity, and improve perfusion to the tissues, which can help resolve the occlusion. While pain management with analgesics is also a top priority, hydration is a key treatment for the underlying pathophysiology. Cold compresses would cause vasoconstriction, worsening the crisis. Ambulation may be too painful, and prophylactic antibiotics, while important, do not address the immediate crisis.
Question 5: A nurse is providing education to a patient newly diagnosed with deep vein thrombosis (DVT) who is being discharged on enoxaparin. Which statement by the patient indicates a need for further teaching?
- "I will have my INR checked weekly to make sure the medication is working." (Correct answer)
- "I should use an electric razor to reduce my risk of getting cut."
- "I will report any signs of unusual bleeding or bruising to my doctor right away."
- "I need to rotate the injection sites on my abdomen."
Correct answer: "I will have my INR checked weekly to make sure the medication is working."
Enoxaparin is a low-molecular-weight heparin (LMWH). Routine coagulation monitoring, such as INR or aPTT, is not required for LMWH as it is for warfarin or unfractionated heparin. This statement indicates a misunderstanding of the medication. The other statements reflect correct understanding of anticoagulant precautions and proper administration technique.
Question 6: A patient is admitted with a suspected pulmonary embolism (PE). The nurse should prioritize which of the following assessments?
- Assessing for a positive Homans' sign.
- Checking for peripheral edema and skin discoloration.
- Monitoring oxygen saturation and respiratory rate. (Correct answer)
- Measuring calf circumference daily.
Correct answer: Monitoring oxygen saturation and respiratory rate.
A pulmonary embolism is a life-threatening condition where a clot obstructs the pulmonary artery, impairing gas exchange. Therefore, the priority assessment is to monitor the patient's respiratory status, including oxygen saturation and respiratory rate, to detect hypoxemia and respiratory distress promptly. While assessing for signs of DVT (peripheral edema, calf circumference, Homans' sign) is important because DVT is the most common cause of PE, the immediate threat to life is respiratory compromise. Homans' sign is also considered an unreliable indicator for DVT.
CMSRN - Medical-Surgical Nursing Cardiovascular and Hematological Care Questions and Answers
A nurse is creating a discharge plan for a 68-year-old patient who underwent a coronary artery bypass graft (CABG).
Which instruction is most important to include to prevent complications related to the sternotomy?