A nurse is admitting a client who reports chest pain.
The nurse is preparing the client for the cardiac catheterization (coronary angiography). Which of the following actions should the nurse take? (Select all that apply.)
Mark the surgical site with an "X
Ask the client about their last food and fluid intake
Educate the client that they will need to keep their leg straight for 6 hours after the procedure.
Ask the client about their prescribed, over the counter, and herbal medication use
Begin prophylactic heparin therapy prior to the procedure
Correct Answer : B,D
A. Marking the surgical site with an "X" is not typically done for cardiac catheterization. Instead, the healthcare provider may mark the site if necessary, but this is usually done by the surgeon or interventional cardiologist.
B. Asking about food and fluid intake is crucial because the client will need to be NPO (nothing by mouth) for several hours before the procedure to reduce the risk of aspiration during sedation or anesthesia.
C. Educating the client about keeping their leg straight after the procedure is necessary, but this typically occurs after the procedure, not before. This helps prevent complications such as bleeding or clot formation at the insertion site.
D. Asking about prescribed, over-the-counter, and herbal medications is important because certain medications, especially anticoagulants and blood thinners, need to be stopped before the procedure to minimize the risk of bleeding during catheterization.
E. Prophylactic heparin therapy may be ordered by the provider, but it is not typically administered by the nurse before the procedure unless specifically ordered.
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Related Questions
Correct Answer is D
Explanation
A. A fasting blood glucose level of 98 mg/dL is within the normal range (70–99 mg/dL), indicating no immediate concern for diabetes.
B. An HDL cholesterol level of 58 mg/dL is considered protective against CAD, as higher HDL levels are associated with a lower risk of heart disease.
C. Triglyceride levels of 120 mg/dL are within the normal range (less than 150 mg/dL), so they do not require follow-up.
D. A total cholesterol level of 210 mg/dL is slightly above the recommended level of less than 200 mg/dL. Elevated cholesterol, particularly LDL cholesterol, is a key modifiable risk factor for coronary artery disease (CAD).
Correct Answer is C
Explanation
A. Temperature is not directly related to the effects of nitroglycerin or the client’s need for additional doses.
B. While oxygen saturation is important, it does not directly influence the decision to administer nitroglycerin, which primarily works to relieve chest pain by dilating coronary arteries and reducing myocardial oxygen demand.
C. Nitroglycerin is a vasodilator that can lower blood pressure. It is crucial to check the client’s blood pressure before administering another dose of nitroglycerin because excessive drops in blood pressure can lead to dizziness, fainting, or other complications. If the blood pressure is already low, further administration may be contraindicated.
D. Apical pulse rate is important to monitor but is not the most critical cue in this scenario. Nitroglycerin primarily affects blood pressure and coronary circulation rather than directly influencing heart rate.
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