A patient had a cardiac catheterization and is now in the recovery area.
What nursing interventions should be included in the plan of care? Select all that apply.

Choice A rationale

Pulmonary edema occurs when fluid backs up into the lungs, usually due to left-sided heart failure. While pericardial fluid can affect heart function, pulmonary edema is not the most immediate or direct complication of fluid accumulation within the pericardial sac itself. Instead, the fluid in the sac creates external pressure on the heart. The focus of care for increased pericardial fluid is the restriction of cardiac filling rather than the primary congestion of the pulmonary vasculature.

Choice B rationale

Cardiac tamponade is a life-threatening condition where the accumulation of fluid in the pericardial sac increases intrapericardial pressure. This pressure prevents the heart chambers from expanding fully during diastole, which severely reduces stroke volume and cardiac output. Common signs include Beck's triad: hypotension, jugular venous distention, and muffled heart sounds. Immediate intervention is required because the heart can eventually stop beating entirely as it becomes unable to fill with blood due to external compression.

Choice C rationale

Pericarditis is the inflammation of the pericardium, which is often the underlying cause of fluid accumulation, known as pericardial effusion. While the nurse monitors for signs of inflammation, the question asks for a complication resulting from the fluid being dangerously increased. Pericarditis is the state of the tissue rather than the acute hemodynamic consequence of fluid volume. Therefore, preventing the functional collapse of the heart takes precedence over managing the inflammatory process in an emergency.

Choice D rationale

Pericardiocentesis is a medical procedure used to drain excess fluid from the pericardial sac to relieve pressure on the heart. It is a treatment modality rather than a complication. The nurse collaborates with the team to perform this procedure in order to treat or prevent cardiac tamponade. Since the question asks for a complication to prevent, choosing a treatment is logically incorrect. The goal is to avoid the physiological crisis that necessitates such an invasive intervention.

Choice A rationale

An open wound near the ankle with serous drainage and pruritus is more characteristic of chronic venous insufficiency rather than an acute arterial crisis. Venous ulcers are typically shallow and moist, and while they require wound care and infection prevention, they do not represent an immediate threat to the limb. This finding indicates chronic disease progression but does not suggest the sudden loss of perfusion that would necessitate an emergency surgical or pharmacological intervention.

Choice B rationale

Lower extremity edema combined with decreased pulses and coolness is common in advanced peripheral artery disease due to chronic poor perfusion and potentially concurrent venous issues. While these findings are significant and require ongoing management, they are often the baseline status for a patient with long-standing PAD. They do not signal the acute, sudden change in status that defines a clinical emergency, unlike the signs of complete arterial occlusion or acute limb ischemia.

Choice C rationale

A murmur at the 5th midclavicular line suggests mitral valve regurgitation or stenosis, and the accompanying dyspnea and edema suggest left-sided heart failure. These are serious cardiovascular symptoms that require evaluation; however, they represent a systemic cardiac issue rather than a localized complication of peripheral artery disease. While the patient needs a cardiac workup, this finding is not the most immediate threat specifically related to the vascular health of the lower extremities in this context.

Choice D rationale

Pain, pallor, and paresthesia are three of the six Ps of acute arterial occlusion, which is a medical emergency. This suggests that blood flow to the distal extremity has been severely compromised or completely blocked, leading to tissue hypoxia. Without immediate intervention, such as heparinization or an emergency embolectomy, the patient is at extremely high risk for irreversible tissue necrosis, gangrene, and eventual limb amputation. This finding takes absolute priority over chronic or non-ischemic symptoms.