After undergoing a cardiac catheterization, a patient has a large puddle of blood under his buttocks.
What should be the nurse’s priority action?

A rationale:

While a shellfish allergy is important information for the healthcare team to be aware of, it is not directly relevant to the cardiac angiogram procedure itself. Shellfish allergies typically involve reactions to iodine-containing contrast dyes, which are not commonly used in cardiac angiograms. The contrast dye used in cardiac angiograms is usually a gadolinium-based contrast agent, which has a different allergy profile.

It's essential to communicate any allergies to the healthcare team, but this information would not necessarily prompt an immediate notification to the physician in the context of a cardiac angiogram.

Choice B rationale:

The patient's last meal time is relevant for some procedures that require sedation or anesthesia, but it's not typically a major concern for a cardiac angiogram.

Patients are often instructed to have a light meal or snack several hours before the procedure, but an exact fasting time is not always necessary. Unless the physician has specifically ordered a strict fasting period for this patient, the nurse would not need to notify the physician immediately about a meal consumed the previous evening.

Choice C rationale:

This statement is the most concerning and would require immediate notification of the physician. Aspirin is a common antiplatelet medication that helps prevent blood clots. It's often prescribed to patients with heart disease to reduce the risk of heart attack and stroke.

Discontinuing aspirin therapy without medical guidance can increase the risk of blood clots, which could be dangerous during a cardiac angiogram. The procedure involves inserting a catheter into the heart's arteries, and there's a risk of clot formation during this process.

If a patient has not taken their aspirin as prescribed, the physician needs to be aware of this to assess the risks and benefits of proceeding with the angiogram and potentially consider alternative medications or interventions to manage the patient's clotting risk.

Choice D rationale:

Metformin is a medication used to treat type 2 diabetes. While it's important for patients to take their medications as prescribed, missing a single dose of metformin is not typically a major concern in the context of a cardiac angiogram.

The nurse would likely remind the patient to take their metformin as soon as possible, but this would not require immediate notification of the physician.

Choice A rationale:

Venous thromboembolism (VTE) is a blood clot that forms in a vein, usually in the legs. It can be a serious condition, as the clot can break loose and travel to the lungs, causing a pulmonary embolism (PE).

Crossing the legs at the knees can impede blood flow in the veins of the legs, increasing the risk of VTE. This is because it compresses the veins, slowing the flow of blood and making it more likely for clots to form.

The patient's statement that they will make sure not to cross their legs when resting in bed demonstrates that they understand this important risk factor for VTE and are taking steps to prevent it.

Choice B rationale:

While keeping pillows under the knees can help to improve circulation, it is not a specific measure to prevent VTE. It is more important to avoid crossing the legs and to engage in regular movement and activity to promote blood flow.

Choice C rationale:

Compression stockings can help to reduce the risk of VTE by compressing the veins in the legs and promoting blood flow. However, they should be worn as instructed by a healthcare professional, and not only if the patient experiences pain in their calves. Pain in the calves can be a symptom of VTE, so it is important to seek medical attention if it occurs.

Choice D rationale:

Bed rest is actually a risk factor for VTE, as it can lead to decreased blood flow in the legs. It is important to get up and move around as soon as possible after surgery, even if it is just for short periods of time. This will help to promote blood flow and reduce the risk of VTE.