In addition to assessing peripheral pulses and auscultating the patient’s heart and lung sounds, which action will be implemented by the nurse before a cardiac catheterization? Select all that apply. One, some, or all responses may be correct.

Instruct the patient to withhold any medication for diuretic therapy.

Prepare to administer fluids 2 hours before the procedure for patients with renal dysfunction.

Advise the patient to take all anticoagulants.

Administer steroids if the patient has an allergy to iodine-based contrast.

Ensure that the patient is NPO for a minimum of 2 hours before the procedure.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A: Instruct the patient to withhold any medication for diuretic therapy.

Reason: Diuretics can lead to dehydration and electrolyte imbalances, which can complicate the cardiac catheterization procedure. Withholding diuretics helps to maintain fluid balance and reduce the risk of complications during the procedure

Choice B: Prepare to administer fluids 2 hours before the procedure for patients with renal dysfunction.

Reason: Administering fluids before the procedure helps to prevent contrast-induced nephropathy, especially in patients with renal dysfunction. Hydration helps to flush out the contrast material used during the procedure, reducing the risk of kidney damage.

Choice C: Advise the patient to take all anticoagulants.

Reason: This choice is incorrect. Patients are usually advised to withhold anticoagulants before a cardiac catheterization to reduce the risk of bleeding complications. The decision to continue or withhold anticoagulants should be based on a careful assessment of the patient’s risk of thromboembolism versus the risk of bleeding.

Choice D: Administer steroids if the patient has an allergy to iodine-based contrast.

Reason: Administering steroids is a common premedication strategy for patients with a known allergy to iodine-based contrast media. Steroids help to reduce the risk of an allergic reaction during the procedure.

Choice E: Ensure that the patient is NPO for a minimum of 2 hours before the procedure.

Reason: Ensuring that the patient is NPO (nothing by mouth) helps to reduce the risk of aspiration during the procedure. Typically, patients are advised to be NPO for 6-8 hours before the procedure, but a minimum of 2 hours is essential.

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Correct Answer is ["A","B","C"]

Explanation

Choice A: Increased Respiratory Rate

Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.

Choice B: Increased Heart Rate

An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.

Choice C: Increased Blood Pressure

Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.

Choice D: Increased Hematocrit

Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.

Choice E: Increased Temperature

Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.

A. Buffalo hump B. Moon face C. Hypertension D. Purple striations E. Tremors

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.

Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.

Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.

Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.

Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.

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In addition to assessing peripheral pulses and auscultating the patient’s heart and lung sounds, which action will be implemented by the nurse before a cardiac catheterization? Select all that apply. One, some, or all responses may be correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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