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.

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Correct Answer is A

Explanation

Choice A Reason
Acute compartment syndrome occurs when bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment – leads to increased pressure. This pressure can impede blood flow to the body tissue and destroy function. The fascia, which is a tough layer of fibrous tissue, does not stretch easily, so any swelling or bleeding can quickly lead to increased pressure.

Choice B Reason
While displaced bones can compress nerves and vessels, this is not the primary mechanism of acute compartment syndrome. Displaced bones are more likely to cause direct injury or impingement, but compartment syndrome specifically refers to the pressure build-up within a muscle compartment that affects circulation and tissue viability.

Choice C Reason
Interruption of blood supply to the bone is a serious concern and can lead to conditions such as avascular necrosis. However, in the context of acute compartment syndrome, the primary issue is the pressure within the muscle compartment rather than direct disruption of blood supply to the bone.

Choice D Reason
Compression of muscle tissue can restrict blood flow to the area, which is a part of the pathophysiology of compartment syndrome. However, the compression is a result of increased pressure within the compartment, not the primary cause. The increased pressure is due to bleeding and swelling, which is why choice A is the most accurate description.

A. Perform a 12-lead electrocardiogram and call a rapid response. B. Elevate the head of the bed and apply 2 liters of nasal oxygen. C. Instruct the client to remain calm and administer lorazepam. D. Increase the intravenous rate from 80 mL to 100 mL/hr.

Correct Answer is B

Explanation

Choice A reason:
Performing a 12-lead electrocardiogram and calling a rapid response team are important steps when a pulmonary embolism is suspected. However, these actions are not the immediate first-line interventions. The priority is to address the client's oxygenation needs to prevent further hypoxemia and potential cardiac arrest.

Choice B reason:
Elevating the head of the bed and applying 2 liters of nasal oxygen is the most appropriate initial intervention. This position helps improve the expansion of the lungs and oxygenation, while the supplemental oxygen can help alleviate hypoxemia, which is critical in the management of a pulmonary embolism.

Choice C reason:
While ensuring the client remains calm is beneficial, administering lorazepam is not the first-line treatment for a suspected pulmonary embolism. Lorazepam may be used for its anxiolytic effects, but it does not address the immediate life-threatening issues of oxygenation and potential hemodynamic instability.

Choice D reason:
Increasing the intravenous rate may be considered to maintain adequate hydration and venous return, but it is not the first intervention for a suspected pulmonary embolism. The priority is to stabilize the client's respiratory status and oxygenation.

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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

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Correct Answer is A

Explanation

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