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 C
Explanation
A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.
B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.
C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.
D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.
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.
