Nokea
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
- A. Administer a radioisotope as ordered.
- B. Give the client a cleansing enema.
- C. Locate and mark peripheral pulses.
- D. Encourage high fluid intake before the test.
Correct Answer: C
Rationale: Locating and marking peripheral pulses before cardiac catheterization allows for post-procedure comparison to detect complications like arterial occlusion. Radioisotopes, enemas, and high fluid intake are not standard preparations for this procedure.
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After the coronary arteriogram, the nurse must keep the client flat in bed with the affected leg in which position?
- A. Extended
- B. Flexed
- C. Abducted
- D. Adducted
Correct Answer: A
Rationale: Keeping the leg extended prevents bleeding or hematoma at the femoral artery puncture site by minimizing movement.
Which response by the nurse is most accurate?
- A. Sustained hypertension decreases thenvim life span of many blood cells.
- B. Sustained hypertension leads to the formation of venous blood clots.
- C. Sustained hypertension compromises blood flow to many vital organs.
- D. Sustained hypertension predisposes to narrowing of the cardiac valves.
Correct Answer: C
Rationale: Sustained hypertension increases vascular resistance, which can compromise blood flow to vital organs like the heart, brain, and kidneys, leading to organ damage.
The nurse responds to the call light of a client who has a history of angina pectoris. He tells the nurse that he has just taken a nitroglycerin tablet sublingually for anginal pain. What action should the nurse take next?
- A. If the pain does not subside within five minutes, place a second tablet under his tongue
- B. Position him with head lower than feet
- C. Administer a narcotic as needed (PRN) for pain if he still has pain in 10 minutes
- D. Call his physician and alert the code team for possible intervention
Correct Answer: A
Rationale: If anginal pain persists five minutes after the first nitroglycerin tablet, a second tablet should be administered, with up to three doses at five-minute intervals. Positioning with head lower than feet, narcotics, or calling the physician are not the immediate next steps.
Based on the client's complaint, the nurse would expect the pain to have which possible effect on the vital signs?
- A. Temperature may be elevated.
- B. Pulse rate may become rapid.
- C. Respiratory rate may slow.
- D. Blood pressure may fall.
Correct Answer: B
Rationale: Acute pain activates the sympathetic nervous system, increasing pulse rate due to stress response.
The client tells the nurse of being extremely frightened. What is the most appropriate action for the nurse to take at this time?
- A. Stay with the client.
- B. Explain the procedures.
- C. Tell the client it will be fine.
- D. Record the collected data.
Correct Answer: A
Rationale: Staying with the client provides emotional support, reducing fear during a crisis.