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.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A) A client's response to interventions implemented: It's essential to document how the client responds to interventions implemented in response to their blood pressure. This provides valuable information on the effectiveness of the interventions and helps in assessing the client's condition.

B) The frequency in which a blood pressure is taken: Documenting the frequency of blood pressure measurements is crucial for tracking trends and changes over time. It ensures a comprehensive assessment of the client's cardiovascular status.

C) Interventions implemented in response to a client's blood pressure: Documenting the interventions implemented in response to a client's blood pressure helps in maintaining an accurate record of the care provided and ensures continuity of care among healthcare providers.

D) The site where the blood pressure was obtained: Documenting the site where the blood pressure was obtained is important for standardizing the measurement process and ensuring consistency. Common sites include the brachial artery, but documenting the specific site provides clarity and accuracy.

E) A client's position when the blood pressure was obtained: Documenting the client's position during blood pressure measurement is essential because blood pressure can vary based on body position. It ensures that accurate comparisons can be made between readings and provides valuable information for clinical decision-making.

A. Headache B. Tachycardia C. Nausea D. Diaphoresis E. Orthopnea

Correct Answer is ["B","C","D"]

Explanation

A. Headache:

Headache is not typically a clinical manifestation of an acute myocardial infarction. The more common symptoms are related to chest pain, autonomic responses, and cardiovascular changes.

B. Tachycardia:

Tachycardia, or an increased heart rate, is a common symptom during an acute MI. This occurs as the body attempts to compensate for decreased cardiac output and perfusion.

C. Nausea:

Nausea is a frequent symptom associated with an acute MI. It results from the activation of the autonomic nervous system during the heart attack.

D. Diaphoresis:

Diaphoresis, or excessive sweating, is a classic symptom of an acute MI. It occurs due to the sympathetic nervous system's response to pain and stress from the heart attack.

E. Orthopnea:

Orthopnea, or difficulty breathing when lying down, is more commonly associated with congestive heart failure rather than an acute MI. While shortness of breath can occur during an MI, orthopnea is not a primary manifestation.

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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?

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Naxlex Comprehensive Predictor Exams

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