The nurse is caring for a client following a cardiac angiogram (catheterization). It would be most important for the nurse to assess the client for:

Bleeding at the arterial puncture site.

Cardiac dysrhythmias related to catheter insertion.

Electrolyte imbalances related to dye injection.

Discomfort at the catheter insertion site.

Answer and Explanation

The Correct Answer is A

Choice a reason:
Bleeding at the arterial puncture site is a primary concern post-cardiac angiogram, as it can lead to significant blood loss and hematoma formation. The nurse must frequently monitor the site for any signs of bleeding or hematoma, apply pressure if necessary, and report any abnormalities to the physician immediately.

Choice b reason:
Cardiac dysrhythmias may occur due to irritation of the heart muscle by the catheter during insertion. Monitoring the client's heart rhythm is essential to detect any new onset of arrhythmias, which could indicate complications from the procedure.

Choice c reason:
Electrolyte imbalances can result from the contrast dye used during a cardiac angiogram. The dye can affect kidney function, leading to changes in electrolyte levels. Monitoring electrolyte levels is important to prevent complications such as arrhythmias or fluid imbalances.

Choice d reason:
While discomfort at the catheter insertion site is expected, it is typically mild. However, the nurse should assess for discomfort as it may indicate other issues such as infection, bleeding, or a reaction to the procedure.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice a reason:
Placing the client on 2L via nasal cannula is a common intervention for hypoxemia, but with the client's pulse oximetry at 88%, which is below the normal range of 95-100%, and the presence of tachypnea, a more immediate assessment of the client's respiratory status is warranted. Oxygen therapy should be guided by the results of arterial blood gas (ABG) analysis to tailor the treatment to the client's specific needs.

Choice b reason:
Obtaining a blood glucose level is not the most immediate concern in the context of altered mental status and respiratory distress. While it is important to rule out hypoglycemia as a cause of altered mental status, the primary concern indicated by the vital signs is the client's respiratory condition.

Choice c reason:
Calling the physician for an order for a stat arterial blood gas is the most appropriate action. The ABG will provide detailed information about the client's oxygenation, carbon dioxide levels, and acid-base balance. This is crucial for a client with a new onset change in mental status and tachypnea, as it can indicate respiratory failure or other serious complications of pneumonia.

Choice d reason:
Requesting an order for lorazepam is not appropriate given the client's current respiratory status. Lorazepam, a benzodiazepine, can depress the central nervous system and respiratory drive, potentially worsening the client's hypoxemia and respiratory effort.

A. "You should increase your fiber intake and include more fresh fruits and vegetables in your diet." B. "Avoid foods high in sugar." C. "Decrease your fluid intake during the day." D. "You should avoid small seeds and nuts."

Correct Answer is A

Explanation

Choice a reason:
Increasing fiber intake is crucial for clients with diverticular disease. A high-fiber diet softens the stool and helps it pass more easily, reducing the pressure in the digestive tract. Fresh fruits and vegetables are excellent sources of fiber and other nutrients essential for maintaining a healthy digestive system. The Dietary Guidelines for Americans recommend a dietary fiber intake of 14 grams per 1,000 calories consumed, which equates to 28 grams per day for a 2,000-calorie diet.

Choice b reason:
While avoiding foods high in sugar is generally good advice for overall health, it is not specifically related to the management of diverticular disease. There is no direct link between sugar intake and the symptoms or complications of diverticular disease. However, a diet high in sugar can contribute to obesity, which is a risk factor for the development of diverticulosis.

Choice c reason:
Decreasing fluid intake is not recommended for clients with diverticular disease. In fact, adequate hydration is essential when increasing fiber intake. Fluids help fiber work better by allowing it to absorb water and expand, aiding in easier passage through the intestines.

Choice d reason:
The previous belief that small seeds and nuts should be avoided by individuals with diverticular disease has been debunked. Recent studies have shown that these foods do not increase the risk of complications and are not harmful to individuals with this condition. Therefore, this advice is outdated and no longer considered necessary as part of dietary teaching for diverticular disease.

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The nurse is caring for a client following a cardiac angiogram (catheterization). It would be most important for the nurse to assess the client for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Correct Answer is C

Explanation

The nurse is caring for a client who has just been diagnosed with diverticular disease. What dietary teaching will the nurse provide?

Correct Answer is A

Explanation

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