A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

Apply a warm pack to the client's puncture site.

Monitor for bleeding at the catheter site.

Replace the client's pressure dressing in 2 hr.

Encourage the client to ambulate in 1 hr.

Answer and Explanation

The Correct Answer is B

A. Apply a warm pack to the client's puncture site. Applying a warm pack to the puncture site is not appropriate immediately following cerebral angiography. Cold compresses are generally recommended initially to reduce swelling and discomfort, while warmth may be used later as advised by the healthcare provider.
B. Monitor for bleeding at the catheter site. Monitoring for bleeding at the catheter site is a critical action after cerebral angiography. The nurse should assess the site frequently for signs of hematoma or excessive bleeding, which can indicate complications from the procedure.
C. Replace the client's pressure dressing in 2 hr. The pressure dressing should not be replaced without specific orders from the healthcare provider. The nurse should assess the dressing for any signs of bleeding or drainage and follow the protocol for dressing changes as indicated.
D. Encourage the client to ambulate in 1 hr. Early ambulation may not be safe immediately after cerebral angiography, especially if the client has undergone a procedure involving sedation or if there is a risk of complications. The nurse should follow the provider's orders regarding activity restrictions and assess the client's readiness for ambulation based on their condition and vital signs.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.

A. Contact children and youth services. B. Administer sexually transmitted infection prophylaxis. C. Provide resources to the client for the local Alcoholics Anonymous chapter. D. Maintain a safe and private environment for the client. E. Request a consult for case management. F. Provide resources for local support services.

Correct Answer is ["B","D","E","F"]

Explanation

A. Contact children and youth services. There is no indication that the client is a minor. Mandatory reporting to child protective services applies to minors, but in the case of an adult client, reporting sexual assault is the client’s decision unless required by law (such as in cases involving incapacitated individuals or threats to public safety).
B. Administer sexually transmitted infection prophylaxis. Clients who have experienced sexual assault should be offered prophylactic treatment for sexually transmitted infections (STIs), including chlamydia, gonorrhea, and trichomoniasis, in accordance with CDC guidelines. Post-exposure prophylaxis for HIV may also be considered based on risk factors.
C. Provide resources to the client for the local Alcoholics Anonymous chapter. The client reports social drinking but has not indicated problematic alcohol use or a desire for treatment. Providing unsolicited resources for Alcoholics Anonymous may not be appropriate in this situation.
D. Maintain a safe and private environment for the client. Ensuring privacy and a safe space is essential for clients who have experienced trauma. The nurse should provide emotional support, minimize interruptions, and allow the client to make decisions regarding care.
E. Request a consult for case management. Case management services can assist with legal considerations, follow-up care, counseling referrals, and safety planning. The nurse should initiate a referral to support the client’s needs.
F. Provide resources for local support services. Sexual assault survivors should receive information about crisis hotlines, advocacy groups, counseling services, and other community resources that can offer emotional and legal support.

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A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

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Explanation

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Explanation

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