Nokea
A client is prescribed a nitroglycerin transdermal patch to treat angina. Which statement does the nurse include when reinforcing medication teaching to the client prior to discharge?
- A. You do not need the effects of this medication while you sleep
- B. The medication patch causes headaches so you should remove it daily
- C. The patch should be worn for 12 hours and then removed for 12 hours
- D. Skin irritation is common when the patch is worn for more than 12 hours
Correct Answer: C
Rationale: A transdermal nitroglycerin patch is prescribed for the prevention of angina pectoris. Nitroglycerin transdermal patches are typically applied for 12 to 14 hours, and then removed for the same amount of time. Though it is true that common adverse effects of nitroglycerin are headaches and contact dermatitis and that there is less demand on the heart when the client rests, these are not the reasons for applying and removing the patch for the same length of time in a 24-hour period.
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The nurse provides care for a client following a percutaneous transluminal coronary angioplasty (PTCA). Which is the priority action by the nurse?
- A. Monitor the gag reflex
- B. Evaluate for signs of infection
- C. Monitor for signs of fluid volume deficit
- D. Palpate distal pulses in bilateral extremities
Correct Answer: D
Rationale: The PTCA is an invasive nonsurgical procedure in which a balloon-tipped catheter is inserted and threaded through a peripheral artery. The nurse monitors the client for bleeding postprocedure in addition to palpating distal, bilateral pulses in the appropriate extremity. Fluid volume deficit is not a primary concern. This procedure does not require general anesthesia; therefore, monitoring for an impaired gag reflex is not a priority nursing action. Signs of infection should be monitored post-PTCA, but this is not an immediate concern.
A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?
- A. I should avoid taking a tub bath until my catheter site heals
- B. I should expect a low-grade fever and swelling at the site for the next week
- C. I should avoid prolonged sitting
- D. I should expect bruising at the catheter site for up to 3 weeks
Correct Answer: B
Rationale: Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.
A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation?
- A. Prothrombin time (PT) or international normalized ratio (INR)
- B. Hourly IV infusion
- C. Vascular sites for bleeding
- D. Urine output
Correct Answer: A
Rationale: The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.
The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
- A. Minimize bowel movements and coughing
- B. Avoid situations that contribute to ischemic episodes
- C. Avoid straining during bowel movements and coughing
- D. Wear wool socks and mittens during cold weather
Correct Answer: C
Rationale: The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. Coughing and straining increase the risk of rupture. The client with Raynaud syndrome is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
- A. Inform client of diagnostic tests
- B. Remove hair from skin insertion sites
- C. Assess distal pulses
- D. Withhold anticoagulant therapy
Correct Answer: D
Rationale: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.