A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Check the client's distal pulses in both legs.

Keep the client overnight.

Keep the client on bed rest for 12 hr.

Restrict the client's oral fluids.

Answer and Explanation

The Correct Answer is A

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Insert the IV catheter:

Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.

B. Obtain a blood sample:

Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.

C. Attach the leads for a 12-lead ECG:

Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.

D. Initiate oxygen therapy:

Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.

A. Obtain the client's consent. B. Describe the consequences of forgoing treatment. C. Witness the client's signature. D. Explain the risks and benefits of the procedure.

Correct Answer is C

Explanation

A. Obtain the client’s consent: It is not the nurse’s responsibility to obtain the client’s consent for a procedure. This responsibility lies with the healthcare provider performing the procedure.

B. Describe the consequences of forgoing treatment: While it’s important for the client to understand the consequences of not undergoing the procedure, it is the healthcare provider’s responsibility to explain these consequences, not the nurses.

C. Witness the client’s signature: This is correct. The nurse’s role in the informed consent process is to witness the client’s signature on the consent form and to verify that the client is consenting voluntarily and appears to be competent to do so.

D. Explain the risks and benefits of the procedure: While the nurse can reinforce information, it is the healthcare provider’s responsibility to explain the risks and benefits of the procedure. The nurse should ensure that the client understands the information provided by the healthcare provider

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

Correct Answer is C

Explanation

A charge nurse is discussing qualitative and quantitative research with a newly licensed nurse. Which of the following statements should the charge nurse make?

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching about warfarin with a client who has a new onset of atrial fibrillation. Which of the following statements should the nurse include in the teaching?

A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medication should the nurse plan to administer first?

A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

A nurse is preparing an in-service about evidence-based practice (EBP). Which of the following information should the nurse include about peer-reviewed sources of information?