1. A nurse assesses a client recovering from coronary artery bypass graft surgery.
Which assessment should the nurse complete to evaluate the clients activity
tolerance?
a. Vital signs before, during, and after activi
...
1. A nurse assesses a client recovering from coronary artery bypass graft surgery.
Which assessment should the nurse complete to evaluate the clients activity
tolerance?
a. Vital signs before, during, and after activity
b. Body image and self-care abilities
c. Ability to use assistive or adaptive devices
d. Clients electrocardiography readings
ANS: A
To see whether a client is tolerating activity, vital signs are measured before, during,
and after the activity. If the client is not tolerating activity, heart rate may increase
more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital
signs will not return to baseline within 5 minutes after the activity. A body image
assessment is not necessary before basic activities are performed. Self-care abilities
and ability to use assistive or adaptive devices is an important assessment when
planning rehabilitation activities, but will not provide essential information about the
clients activity tolerance. Electrocardiography is not used to monitor clients in a
rehabilitation setting.
2. A nurse prepares a client for coronary artery bypass graft surgery. The client
states, I am afraid I might die. How should the nurse respond?
a. This is a routine surgery and the risk of death is very low.
b. Would you like to speak with a chaplain prior to surgery?
c. Tell me more about your concerns about the surgery.
d. What support systems do you have to assist you?
ANS: C
The nurse should discuss the clients feelings and concerns related to the surgery.
The nurse should not provide false hope or push the clients concerns off on the
chaplain. The nurse should address support systems after addressing the clients
current issue.
3. A nurse is assessing clients on a medical-surgical unit. Which client should the
nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is post coronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common
occurrence after coronary artery bypass graft surgery. The other conditions do not
place these clients at higher risk for atrial fibrillation.
4. A nurse is in charge of the coronary intensive care unit. Which client should the
nurse see first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100
mm Hg
c. Client who is 1 day post percutaneous coronary intervention, going home this
morning
d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m.
while walking
ANS: B
Hypertension after coronary artery bypass graft surgery can be dangerous because
it puts too much pressure on the suture lines and can cause bleeding. The charge
nurse should see this client first. The client who became dizzy earlier should be
seen next. The client on the nitroglycerin drip is stable. The client going home can
wait until the other clients are cared for.
Activity Tolerance/Angina- Ch6
5. A nurse teaches a client with a past history of angina who has had a total knee
replacement. Which statement should the nurse include in this clients teaching prior
to beginning rehabilitation activities?
a. Use analgesics before and after activity, even if you are not experiencing pain.
b. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
c. Do not take your prescribed beta blocker until after you exercise with physical
therapy.
d. If you experience knee pain, ask the physical therapist to reschedule your
therapy.
ANS: B
Participation in exercise may increase myocardial oxygen demand beyond the
ability of the coronary circulation to deliver enough oxygen to meet the increased
need. The nurse must determine the clients ability to tolerate different activity
levels. Asking the client to notify the nurse if symptoms of shortness of breath,
chest pain, or fatigue occur will assist the nurse in developing an appropriate
cardiac rehabilitation plan.
Ambulation/Older Adult- Ch6
6. A nurse delegates the ambulation of an older adult client to an unlicensed
nursing assistant (UAP). Which statement should the nurse include when delegating
this task?
a. The client has skid-proof socks, so there is no need to use your gait belt.
b. Teach the client how to use the walker while you are ambulating up the hall.
c. Sit the client on the edge of the bed with legs dangling before ambulating.
d. Ask the client if pain medication is needed before you walk the client in the hall.
ANS: C
Before the client gets out of bed, have the client sit on the bed with legs dangling
on the side. This will enhance safety for the client. A gait belt should be used for all
clients. The UAP cannot teach the client to use a walker or assess the clients pain.
7. A nurse assists a client with left-sided weakness to walk with a cane. What is the
correct order of steps for gait training with a cane?
1. Apply a transfer belt around the clients waist.
2. Move the cane and left leg forward at the same time.
3. Guide the client to a standing position.
4. Move the right leg one step forward.
5. Place the cane in the clients right hand.
6. Check balance and repeat the sequence.
a. 3, 1, 5, 4, 2, 6
b. 1, 3, 5, 2, 4, 6
c. 5, 3, 1, 2, 4, 6
d. 3, 5, 1, 4, 2, 6
ANS: B
To ambulate a client with a cane, the nurse should first apply a transfer belt around
the clients waist, then guide the client to a standing position and place the cane in
the clients strong hand. Next the nurse should assist the client to move the cane
and weaker leg forward together. Then move the stronger leg forward and check
balance before repeating the sequence.
Spinal Cord Injury/Cred Bladder- Ch6
8. A nurse is caring for a client who has a spinal cord injury at level T3. Which
intervention should the nurse implement to assist with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Cred maneuver every 3 hours.
d. Apply a Texas catheter with a leg bag.
ANS: C
Two techniques are used to facilitate voiding in a client with a flaccid bladder: the
Valsalva maneuver and the Cred maneuver. Indwelling urinary catheters generally
are not used because of the increased incidence of urinary tract infection. Stroking
the medial aspect of the thigh facilitates voiding in clients with upper motor neuron
problems. If the spinal cord injury is above T12, the client is unaware of a full
bladder and does not void or is incontinent. Therefore, the client would not benefit
from a Texas catheter with a leg bag.
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