The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?
2+ bilateral peripheral edema
Heart rate 59 beats/min
Temperature of 96 F
Muffled heart sounds
The Correct Answer is D
A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.
B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.
C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.
D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypercalcemia (Calcium > 10.5 mg/dL) can lead to shortened QT intervals, not prolonged ones, and is unlikely to cause Torsades de Pointes.
B. A magnesium level of 3.1 mEq/L is slightly elevated and would not contribute to QT prolongation or Torsades de Pointes. In fact, magnesium supplementation is a treatment for this condition.
C. Hypokalemia (Potassium < 3.5 mEq/L) can prolong the QT interval and contribute to dysrhythmias, but it is less commonly a direct cause of Torsades de Pointes compared to hypomagnesemia. A potassium level of 2.6 mEq/L is low but would not typically result in Torsades without coexisting hypomagnesemia.
D. Hypomagnesemia (Magnesium < 1.5 mEq/L) disrupts the heart's electrical activity, prolonging the QT interval and increasing the risk of polymorphic ventricular tachycardia, like Torsades de Pointes. Magnesium is critical for stabilizing myocardial electrical conduction, and a value of 1.1 mEq/L indicates significant deficiency, consistent with this dysrhythmia.
Correct Answer is D
Explanation
A. Magnetic resonance imaging (MRI) may be used in some cases, but TRUS is more commonly used to guide biopsies after concerns arise from DRE or PSA findings.
B. Uroflowmetry studies measure urine flow, which is not the primary concern in evaluating an enlarged prostate related to potential cancer.
C. Cystourethroscopy is used to evaluate the bladder or urethra and is not typically needed in the assessment of an enlarged prostate.
D. Transrectal ultrasonography (TRUS) is commonly used in the evaluation of prostate abnormalities, especially when there are concerns about prostate cancer due to an abnormal DRE or elevated PSA. It helps in visualizing the prostate and guiding biopsy.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.