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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason
Monitoring for hypoglycemia at 1200 is not optimal because it is well past the peak action time of insulin aspart, which occurs approximately 45–90 minutes after administration. By noon, the insulin's effects are waning, and the risk of hypoglycemia is lower compared to the peak action period.
Choice B Reason
Monitoring at 1000 might still catch the tail end of the peak action time, but it is not the most likely time for hypoglycemia to occur. The nurse could miss the initial signs of hypoglycemia if monitoring starts two hours after administration.
Choice C Reason
0900 is the most appropriate time for the nurse to monitor for hypoglycemia. Insulin aspart has a rapid onset of action, peaking in about 45–90 minutes, and the effects last for 3–5 hours. Monitoring one hour after administration aligns with the start of the peak action time, when hypoglycemia is most likely to occur.
Choice D Reason
Monitoring at 1100 is less ideal because it is nearing the end of the peak action period. While there is still a risk for hypoglycemia, the highest risk would have been earlier, closer to the peak action time.
Correct Answer is D
Explanation
Choice A Reason:
Avoiding frustration by performing activities of daily living (ADLs) for the client may seem helpful, but it can actually lead to increased dependency and a faster decline in the ability to perform these tasks. It is important to encourage independence as much as possible.
Choice B Reason:
Telling jokes or riddles and discussing new items might provide temporary entertainment but does not necessarily help a client with dementia function better in their environment. It could also potentially cause confusion or frustration if the client does not understand or remember the context.
Choice C Reason:
Bringing new topics and options to the client's attention can be overwhelming and may contribute to confusion. Clients with dementia benefit from consistency and routine, which helps them feel more secure and oriented.
Choice D Reason:
Assisting the client to perform simple tasks by giving step-by-step directions is a beneficial intervention. It supports the client's ability to maintain independence and function within their environment for as long as possible. This approach aligns with the goal of maximizing the client's abilities and fostering a sense of accomplishment.
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