A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

"You should expect to feel some tingling in the affected limb the day following the procedure."

"You might be asked to perform mild exercises during the procedure."

"You should not eat or drink for 4 hr following the procedure."

"You might have to lie in bed for 6 hr after the procedure."

Answer and Explanation

The Correct Answer is D

A. "You should expect to feel some tingling in the affected limb the day following the procedure." Tingling in the limb could indicate nerve or circulatory problems and should be reported immediately. It is not a normal post-procedure expectation.

B. "You might be asked to perform mild exercises during the procedure." Clients are typically instructed to remain still during a cardiac catheterization to avoid complications at the insertion site. Mild exercises are not a part of the procedure.

C. "You should not eat or drink for 4 hr following the procedure." NPO (nothing by mouth) status is usually required before the procedure, not after. Clients are encouraged to drink fluids after the procedure to help flush the contrast dye from their system.

D. "You might have to lie in bed for 6 hr after the procedure." After a cardiac catheterization, especially with a femoral artery approach, clients may be required to remain on bed rest for 4-6 hours to prevent bleeding or complications at the catheter insertion site.

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Correct Answer is B

Explanation

A. Wrapping the cuff too loosely around the client's arm: A loosely wrapped cuff can cause an inaccurately high reading, not a low one.

B. Positioning the client's arm above heart level: If the client’s arm is positioned above heart level, the blood pressure reading may be inaccurately low. Blood pressure measurements should always be taken with the arm at heart level.

C. Deflating the cuff too slowly: Deflating the cuff too slowly typically leads to an inaccurately high reading, not a low one.

D. Measuring blood pressure right after the client's mealtime: While digestion can sometimes cause a slight drop in blood pressure, it is not typically a significant factor in obtaining an unusually low reading.

A. "The client may benefit from a neurology consult." B. "The client is disoriented and pupils are slow to respond to light." C. "The client has developed drooping facial features." D. "The client has a history of hypertension."

Correct Answer is D

Explanation

A. "The client may benefit from a neurology consult." This statement is more appropriate for the recommendation component of SBAR. The background should focus on what has already occurred or is known, not what the nurse thinks should be done next.

B. "The client is disoriented and pupils are slow to respond to light." This would be part of the assessment component of SBAR, which describes the nurse's evaluation of the current condition.

C. "The client has developed drooping facial features." This statement can be included in theSituationcomponent because it describes the immediate concern that prompted the communication.

D. "The client has a history of hypertension." This statement is suitable for theBackgroundcomponent. It provides relevant medical history that helps the provider understand the context of the current situation.

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A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

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Naxlex Comprehensive Predictor Exams

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is D

Explanation

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