A patient returns to the cardiac floor following a Cardiac Angiogram with Stent placement.
What nursing interventions should be carried out? (Select all that apply)

Monitor insertion site for hematoma and bleeding.

Maintain patient on bedrest.

Monitor patient for dysrhythmias.

Assess heart sounds.

Answer and Explanation

Correct Answer : A,C,D

Rationale for Choice A:

Monitoring the insertion site for hematoma and bleeding is crucial following cardiac angiogram with stent placement. Here's a detailed explanation:

Vascular Injury: The procedure involves accessing a major artery, usually the femoral artery in the groin. This creates a risk of bleeding or hematoma formation at the puncture site.

Anticoagulation: Patients often receive anticoagulant medications during and after the procedure to prevent blood clots from forming around the stent. These medications can increase the risk of bleeding.

Early Detection and Intervention: Prompt identification of bleeding or hematoma formation is essential to prevent complications such as hypotension, shock, or compartment syndrome.

Assessment: Regular assessment of the insertion site includes:

Visual inspection for swelling, bruising, or active bleeding.

Palpation for tenderness, firmness, or expanding hematoma.

Monitoring vital signs for tachycardia, hypotension, or signs of shock.

Interventions: If bleeding or hematoma is detected:

Apply direct pressure to the site.

Notify the healthcare provider immediately.

Implement additional measures as prescribed, such as reversal of anticoagulation or surgical intervention.

Rationale for Choice B:

Maintaining strict bedrest after cardiac angiogram with stent placement is no longer routinely recommended. Here's why:

Early Ambulation Benefits: Research has shown that early ambulation (usually within 6-8 hours) is associated with several benefits, including:

Reduced risk of deep vein thrombosis (DVT)

Improved circulation

Quicker recovery

Shorter hospital stays

Individualized Assessment: The decision regarding ambulation timing should be individualized based on patient factors such as:

Bleeding risk

Procedural complications

Overall health status

Comfort level

Balanced Approach: While early ambulation is encouraged, it's important to balance activity with rest to promote healing and prevent complications.

Rationale for Choice C:

Monitoring for dysrhythmias is essential following cardiac angiogram with stent placement due to several reasons:

Cardiac Irritation: The procedure involves manipulation of catheters and devices within the heart, which can potentially irritate the heart's electrical system.

Electrolyte Imbalances: Contrast dye used during the procedure can cause electrolyte imbalances, which can also trigger dysrhythmias.

Underlying Heart Disease: Patients undergoing angioplasty often have underlying heart disease, which already predisposes them to rhythm disturbances.

Early Detection and Intervention: Prompt identification of dysrhythmias allows for timely interventions to prevent hemodynamic instability, heart failure, or cardiac arrest.

Continuous Monitoring: Continuous ECG monitoring is typically used to detect dysrhythmias, and patients are closely observed for symptoms such as palpitations, lightheadedness, or chest pain.

Rationale for Choice D:

Assessing heart sounds is a crucial nursing intervention following cardiac angiogram with stent placement. Here's why:

Stent Placement Effects: The placement of a stent can alter blood flow patterns within the coronary arteries, which may be audible as changes in heart sounds.

Complication Detection: Heart sounds can provide valuable clues about potential complications such as:

Pericardial effusion (fluid around the heart)

Myocardial infarction (heart attack)

Valvular dysfunction

Baseline Assessment: It's important to establish a baseline assessment of heart sounds prior to the procedure to compare with post-procedure findings.

Regular Auscultation: Regular auscultation of heart sounds should be performed to monitor for changes and promptly report any concerns to the healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Atrial fibrillation (AF) is characterized by the absence of P waves on the ECG, the presence of fibrillatory waves, and an irregularly irregular rhythm. This is due to chaotic electrical activity in the atria, which results in disorganized atrial contractions. The fibrillatory waves, which are often described as "f" waves or "sawtooth" waves, represent the rapid and irregular electrical activity in the atria. They are typically best seen in lead II, V1, or V2 of the ECG.

Here is a more detailed explanation of the key features of AF that support this answer:

Absence of P waves: In normal sinus rhythm, the P wave represents the electrical impulse that originates in the sinoatrial (SA) node and depolarizes the atria. In AF, the SA node is no longer in control of the atrial rhythm, and there is no organized atrial depolarization. As a result, P waves are absent on the ECG.

Presence of fibrillatory waves: The fibrillatory waves seen in AF represent the disorganized electrical activity in the atria. They are typically irregular in amplitude and frequency, and they can vary in appearance from patient to patient.

Irregularly irregular rhythm: The ventricular rhythm in AF is also irregular because the impulses from the atria are not conducted to the ventricles in a regular pattern. This results in an irregularly irregular rhythm, which is a hallmark feature of AF.

Key points to remember:

AF is the most common type of cardiac arrhythmia.

It can be asymptomatic or cause a variety of symptoms, including palpitations, shortness of breath, fatigue, and lightheadedness.

AF is a risk factor for stroke and heart failure.

Treatment for AF may include medications to control heart rate or rhythm, blood thinners to reduce the risk of stroke, and in some cases, procedures to restore normal heart rhythm.

A. Assess lung sounds prior to administration B. Assess systolic blood pressure 10 minutes prior to administration C. Assess brachial pulse for 30 seconds D. Assess apical pulse for 60 seconds

Correct Answer is D

Explanation

Choice A rationale:

Assessing lung sounds is important for evaluating respiratory status, but it is not the priority assessment before administering digoxin. Digoxin does not have a direct effect on the respiratory system, and changes in lung sounds would not necessarily indicate a contraindication to its administration.

However, in patients with heart failure, which is a common indication for digoxin, auscultating lung sounds can provide valuable information about fluid status and the effectiveness of treatment. Therefore, while not the priority assessment, lung auscultation remains a relevant part of the overall assessment of a patient receiving digoxin.

Choice B rationale:

Assessing systolic blood pressure is important for monitoring hemodynamic status, but it is not the most critical assessment before administering digoxin. Digoxin does not directly affect blood pressure, and changes in blood pressure would not necessarily indicate a contraindication to its administration.

However, in patients with hypertension, which can be a factor in heart failure, monitoring blood pressure is essential for managing overall cardiovascular health. Therefore, while not the priority assessment, blood pressure measurement remains an important aspect of care for patients receiving digoxin.

Choice C rationale:

Assessing the brachial pulse for 30 seconds can provide a general assessment of heart rate and rhythm, but it is not as accurate as assessing the apical pulse for a full minute.

The apical pulse is the most reliable way to assess heart rate and rhythm, especially in patients with irregular heartbeats or those taking medications that can affect heart rate, such as digoxin.

Therefore, assessing the apical pulse for a full minute is essential to ensure accurate assessment of the patient's cardiac status before administering digoxin.

Choice D rationale:

Assessing the apical pulse for 60 seconds is the priority assessment before administering digoxin. This is because digoxin is a cardiac glycoside that affects the heart's electrical conduction system and can slow the heart rate. It is essential to assess the patient's heart rate and rhythm before administering digoxin to ensure that it is safe to do so.

A slow heart rate (bradycardia), irregular heart rhythms (such as atrial fibrillation), or certain heart block conditions can be contraindications to digoxin administration or require dosage adjustments.

By accurately assessing the apical pulse for a full minute, the nurse can identify any potential contraindications or concerns and ensure the safe administration of digoxin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient returns to the cardiac floor following a Cardiac Angiogram with Stent placement. What nursing interventions should be carried out? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient’s cardiac rhythm suddenly changes on the monitor. There are no P waves, instead there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

Correct Answer is A

Explanation

A nurse is administering digoxin to a patient. What priority assessment needs to take place prior to administration?

Correct Answer is D

Explanation

The nurse is conducting patient teaching about cholesterol levels. When discussing the patient’s elevated LDL and lowered HDL levels, which statement by the patient indicates an understanding of the significance of these levels?

A patient is scheduled for catheter ablation therapy. When describing this procedure to the patient’s family, what aspect of the treatment should the nurse address?

Please identify the following rhythm:

An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement?

An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg. What nursing diagnosis should be identified in the client’s plan of care?

The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the patient’s most recent cardiac imaging, which notes the presence of scarring on the atria.

A patient with sinus bradycardia has a heart rate of 45 and a blood pressure of 82/60 and is reporting dizziness. What intervention should the nurse anticipate will be ordered?

Please identify the following rhythm:

A patient returns to the cardiac floor following a Cardiac Angiogram with Stent placement.
What nursing interventions should be carried out? (Select all that apply)