A nurse is assisting with the plan of care for a client immediately following a cardiac catheterization with coronary angiography. An arterial closure device was used to close the access site. Which of the following interventions should the nurse recommend?
Elevate the head of the bed 45 degrees.
Limit fluid intake for 4 hr after the procedure.
Have the client rest in bed for 2 hr.
Insert an indwelling urinary catheter 1 hr post procedure.
The Correct Answer is C
A. Elevate the head of the bed 45 degrees. The head of the bed should not be elevated this high, as this can increase pressure on the arterial access site, risking bleeding or disruption of the closure device.
B. Limit fluid intake for 4 hr after the procedure. Fluids should actually be encouraged to help flush out contrast dye used during the procedure and to maintain hydration. Limiting fluids could increase the risk of renal complications.
C. Have the client rest in bed for 2 hr. Bed rest is typically required after cardiac catheterization, especially with the use of an arterial closure device. Two hours is a reasonable time for initial bed rest following the procedure.
D. Insert an indwelling urinary catheter 1 hr post procedure. A urinary catheter is not routinely required after a cardiac catheterization unless there are specific medical indications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bradycardia: Atenolol can slow the heart rate as it reduces the workload of the heart. Bradycardia (a heart rate below 60 beats per minute) is a potential adverse effect and should be monitored.
B. Dry Cough: A dry cough is a common side effect of ACE inhibitors, not beta-blockers like atenolol. This statement is incorrect.
C. Migraine Headache: Atenolol is sometimes used to prevent migraines, not cause them. Therefore, migraines are not an expected adverse effect of atenolol. This statement is incorrect.
D. Insomnia or Hyperactivity: Atenolol can cause fatigue or lethargy, but insomnia or hyperactivity is not a typical side effect. This statement is incorrect.
Correct Answer is ["B","D","E","F","G"]
Explanation
A. Neurological assessment: The neurological assessment indicates the client is alert and oriented, which is good; however, it does not require immediate follow-up.
B. Vital signs: The vital signs indicate an elevated heart rate (138/min), elevated respiratory rate (28/min), and borderline low blood pressure (96/75 mm Hg). These findings suggest potential hemodynamic instability and require immediate attention to assess the underlying cause and determine the appropriate interventions.
C. Basic Metabolic Profile (BMP) laboratory report: The BMP is largely within normal limits except for the glucose level (148 mg/dL), which is slightly elevated but not critically so. There is no urgent need for follow-up based on the BMP findings unless other symptoms arise.
D. Cardiac enzymes laboratory report: The troponin level is elevated (10.1 ng/mL), indicating myocardial injury, which requires immediate follow-up to assess the risk of acute coronary syndrome or worsening heart failure. This is a critical finding that warrants further evaluation.
E. B-natriuretic peptide (BNP) laboratory report: The BNP level is significantly elevated at 800 ng/mL, indicating worsening heart failure. This finding requires immediate follow-up to assess the client's condition and determine appropriate management strategies.
F. Respiratory assessment: The respiratory assessment shows an elevated respiratory rate (28/min) and oxygen saturation at 93% on supplemental oxygen. The presence of pink-tinged sputum may indicate pulmonary congestion or possible pulmonary edema, necessitating immediate follow-up.
G. ECG report: The ECG shows atrial fibrillation with a rapid ventricular response (RVR) at a rate of 135/min. This irregular heart rate can lead to decreased cardiac output and increased risk of thromboembolic events, requiring immediate follow-up to manage the heart rate and rhythm appropriately.
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