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When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to:
- A. check peripheral pulses.
- B. maintain NPO.
- C. apply heat to the insertion site.
- D. start range of motion exercises immediately.
Correct Answer: A
Rationale: Checking peripheral pulses post-cardiac catheterization is essential to detect complications like arterial occlusion or hematoma at the insertion site. Maintaining NPO, applying heat, or starting range of motion exercises immediately are not standard priorities.
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Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
As part of the discharge instructions, the nurse correctly instructs the client that which symptom is a sign of artificial pacemaker malfunction?
- A. Tingling in the chest area
- B. Dizziness during activity
- C. Pain radiating to the arm
- D. Tenderness beneath the skin
Correct Answer: B
Rationale: Dizziness during activity may indicate pacemaker failure to maintain adequate heart rate.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. Which instructions should be included? Select all that apply.
- A. Take a shower rather than a tub bath until the puncture site heals.
- B. Perform leg exercises every 2 hours while awake.
- C. In the generous amount of fluids for the next 24 hours.
- D. Report worsening of pain in the leg that was catheterized.
- E. Flush the toilet twice after eliminating urine and stool in the next 24 hours.
- F. Change the dressing over the puncture site daily until it heals.
Correct Answer: A,C,D
Rationale: Showering prevents infection, generous fluids help flush contrast dye, and reporting worsening pain detects complications. Leg exercises, double flushing, and daily dressing changes are not standard.