Nokea
The nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. Which information should the nurse share with the client regarding the procedure?
- A. The procedure is performed in the operating room.
- B. The initial catheter insertion is quite painful; after that, there is little or no pain.
- C. You may feel fatigue and have various aches because it is necessary to lie quietly on a stationary x-ray table for about 4 hours.
- D. You may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations.
Correct Answer: D
Rationale: Cardiac catheterization is an invasive test that involves the insertion of a catheter and the injection of dye into the heart and surrounding vessels to obtain information about the structure and function of the heart chambers and valves and the coronary circulation. Access is made by the insertion of a needle in either side of the groin into an artery and the catheter is advanced up to the heart through the abdomen and chest. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so that there is little to no pain with catheter insertion. The x-ray table is hard but can be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.
You may also like to solve these questions
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
- A. Pain level
- B. Vital signs
- C. Hourly urine output
- D. Tolerance for sips of clear liquids
- E. Ability to cough and deep breathe
Correct Answer: A,B,C,E
Rationale: After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.
The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.
- A. Assess pulses and circulation proximal to the fistula.
- B. Palpate for thrills and auscultate for a bruit every 4 hours.
- C. Check for bleeding and infection at hemodialysis needle insertion sites.
- D. Avoid taking blood pressure or performing venipunctures in the extremity.
- E. Instruct the client not to carry heavy objects or anything that compresses the extremity.
- F. Instruct the client not to sleep in a position that places her or his body weight on top of the extremity.
Correct Answer: B,C,D,E,F
Rationale: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: palpate for thrills and auscultate for a bruit every 4 hours, check for bleeding and infection at hemodialysis needle insertion sites, avoid taking blood pressures or performing venipunctures in the extremity, instruct the client not to carry heavy objects or anything that compresses the extremity, instruct the client not to sleep in a position that places the body weight on top of the extremity, and the nurse should assess pulses and circulation distal to the fistula.
A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to vomit, and reports being dizzy and having a headache. Based on these data, which is the most important nursing action?
- A. Administering a prescribed antiemetic
- B. Notifying the primary health care provider of the client's condition
- C. Having the client rate the headache pain on a scale of 1 to 10
- D. Reminding the client to use the call bell when needing help to the bathroom
Correct Answer: B
Rationale: The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing action is to notify the primary health care provider. Although the other nursing actions are not inappropriate, none of them address the critical issue of the potential of the client developing ICP.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply.
- A. Dizziness
- B. Bradycardia
- C. Chest pain
- D. Reflex tachycardia
- E. Sexual dysfunction
- F. Cardiac dysrhythmias
Correct Answer: A,B,E
Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.