A nurse is preparing a client for a scheduled Percutaneous Coronary Intervention (PCI). Which statement made by the client should the nurse report to the Primary Healthcare Provider (PHCP)?
“I am allergic to shellfish.”.
“I may feel a warm sensation during the procedure.”.
“I get anxious when I am in closed spaces.”.
“I took my metformin this morning.”.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Allergies to shellfish may indicate iodine allergy, relevant for procedures using iodine-based contrast, like PCI. The client’s shellfish allergy must be reported to the PHCP as a precautionary measure to prevent any allergic reaction.
Choice B rationale: Warm sensations during PCI are a common side effect of the contrast dye used in the procedure. This statement does not indicate an immediate concern requiring PHCP notification as it is a standard patient experience.
Choice C rationale: Anxiety in closed spaces, known as claustrophobia, may affect the client's comfort during PCI but can be managed with sedatives. The PHCP should be aware but it’s not as urgent as taking contraindicated medications.
Choice D rationale: Metformin can lead to lactic acidosis, especially when iodine contrast dye is used during PCI. This condition is serious and may result in adverse interactions. The PHCP must be notified immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Redness on both sides of the sternal incision could indicate a normal inflammatory response post-surgery or could be a sign of infection. However, it is not the most crucial observation to report in the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft.
Choice B rationale
Fine crackles heard at both lung bases could indicate fluid accumulation in the lungs, possibly due to heart failure or pneumonia. While this is a significant finding that requires further investigation, it is not the most crucial observation in this specific context.
Choice C rationale
Complaints of incisional chest pain are common after coronary artery bypass grafting. Pain management is an important part of post-operative care, but this symptom is not the most crucial to report in this context.
Choice D rationale
Pallor and weakness of the right hand could indicate compromised blood flow to the hand, which is a serious complication considering the right radial artery was used for the graft. This could lead to ischemia and tissue damage in the hand, thus it is the most crucial observation to report to the healthcare provider.
Correct Answer is A
Explanation
Choice A rationale
Clubbed fingers can be a symptom of conditions such as endocarditis, a heart condition that involves inflammation of the inner lining of the heart.
Choice B rationale
While myocardial infarction (heart attack) is a serious condition, it is not typically associated with clubbing of the fingers.
Choice C rationale
Acute kidney injury does not typically cause clubbing of the fingers.
Choice D rationale
Chronic thrombophlebitis, a condition characterized by inflammation and blood clots in the veins, is not typically associated with clubbing of the fingers.
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