A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

Obtain the client's vital signs.

Witness the client's signature on the Informed consent form.

Confirm the client's allergies.

inform the client of the risks of the procedure.

Mark the surgical site.

Answer and Explanation

Correct Answer : A,B,C

A. Obtain the client's vital signs: This is correct. Vital signs should be assessed to monitor the client's cardiovascular status before any invasive procedure, especially in the context of a myocardial infarction.
B. Witness the client's signature on the informed consent form: This is correct. The nurse should witness the client's signature on the informed consent form, ensuring that the client understands the procedure and consents to it.
C. Confirm the client's allergies: This is correct. Confirming allergies is crucial before any procedure to prevent allergic reactions to medications, contrast dye, or other substances used during the procedure.
D. Inform the client of the risks of the procedure: This is incorrect. It is the responsibility of the provider to explain the risks of the procedure in detail to the client. The nurse ensures that the client understands and that consent is given, but the nurse does not provide the detailed explanation of risks.
E. Mark the surgical site: This is incorrect. Marking the surgical site is typically done by the provider, not the nurse, and is required only if a surgical procedure is being performed, which is not the case for a cardiac catheterization.

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Correct Answer is B

Explanation

A. Furosemide is a loop diuretic that primarily causes hypokalemia (low potassium levels) and does not typically cause hyperkalemia. It can also cause dehydration and hyponatremia, but it is not associated with both hyperkalemia and hyponatremia.
B. Spironolactone is a potassium-sparing diuretic. It helps retain potassium while excreting sodium and water, which increases the risk for hyperkalemia (high potassium) and hyponatremia (low sodium) when used in combination with other medications that affect electrolyte balance.
C. Metolazone is a thiazide-like diuretic that can cause hypokalemia and hyponatremia, but it is not typically associated with hyperkalemia.
D. Hydrochlorothiazide is a thiazide diuretic that can cause hypokalemia and hyponatremia, but it does not increase the risk of hyperkalemia.

A. Ascites B. Biliary colic C. Bile stasis D. Hepatitis

Correct Answer is C

Explanation

A. Ascites is the accumulation of fluid in the peritoneal cavity, often due to liver disease such as cirrhosis. It does not directly cause the formation of biliary sludge, which is related to bile composition and flow.
B. Biliary colic refers to pain caused by the gallbladder's inability to expel bile, often due to a gallstone blocking the bile duct. While biliary colic may be associated with gallstones, it is not the primary cause of biliary sludge.
C. Bile stasis is the primary cause of biliary sludge. It occurs when bile remains in the gallbladder for an extended period, leading to the formation of thickened bile and sludge. Factors such as fasting, pregnancy, or liver disease can contribute to bile stasis.
D. Hepatitis is an inflammation of the liver, which may affect bile production but does not directly cause biliary sludge. Hepatitis can lead to other complications such as jaundice but is not the main cause of biliary sludge formation.

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A nurse is admitting a client who reports chest pain. Exhibits The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

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A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)