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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The best response is to educate the client about the cause of Prinzmetal angina. It occurs due to spasm in the coronary arteries, which is different from the plaque buildup seen in traditional coronary artery disease. This response addresses the client's concern in an accurate and reassuring manner.

B. While healthy eating is important, Prinzmetal angina is not typically caused by cholesterol or plaque buildup. This response could increase the client's anxiety.

C. While acknowledging the client's emotions is important, this response does not address the underlying concern or provide an accurate explanation of Prinzmetal angina.

D. Offering reassurance without providing accurate information about the condition does not help the client understand the cause of their symptoms and could leave them confused or anxious.

A. Client with a blood pressure of 90/50 mm Hg. B. Client with a temperature of 96° F (35.6° C). C. Client with a pulse of 118 beats/min. D. Client with a respiratory rate of 6 breaths/min.

Correct Answer is D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

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