A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?

Encourage the client to ambulate within 30 min following the procedure.

Keep the client NPO for at least 2 hr following the procedure.

Assess pulses in the client's affected arm.

Apply light pressure to the insertion site.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.

Choice B rationale

Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.

Choice C rationale

Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.

Choice D rationale

Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .

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Correct Answer is C

Explanation

Choice A rationale

Intestinal malabsorption syndrome is not typically associated with ulcerative colitis or anemia caused by this condition. Malabsorption is more often related to other gastrointestinal conditions.

Choice B rationale

Intestinal parasites are not a common cause of anemia in individuals with ulcerative colitis. The chronic inflammation and blood loss are more likely contributors.

Choice C rationale

Chronic blood loss from the intestinal lining due to ulcerative colitis is a major contributing factor to anemia. The ongoing inflammation and ulceration can cause significant blood loss over time.

Choice D rationale

Dietary iron restrictions are not typically associated with ulcerative colitis. Anemia in this context is more likely due to chronic blood loss rather than dietary deficiencies.

A. Obtain an ECG. B. Call the Rapid Response Team. C. Administer another nitroglycerin tablet. D. Initiate a peripheral IV.

Correct Answer is C

Explanation

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.

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A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

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A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?