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 D

Explanation

Choice A Reason
A potassium level of 5.0 mEq/L is at the upper limit of the normal range, which is typically between 3.5 and 5.0 mEq/L. While this level should be monitored, especially in the context of diabetes where the patient may be at risk for hyperkalemia due to potential kidney issues, it is not immediately alarming¹.

Choice B Reason
A creatinine level of 4.4 mg/dL is significantly higher than the normal range of 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates severe renal impairment or kidney failure, which is a serious complication of diabetes mellitus. Immediate intervention is required to address this critical issue¹.

Choice C Reason
A hemoglobin level of 10.7 g/dL is slightly below the normal range for adults, which is generally 13.8 to 17.2 g/dL for males and 12.1 to 15.1 g/dL for females. This could indicate mild anemia, which can be a complication of diabetes but is not as immediately concerning as a high creatinine level¹.

Choice D Reason
A Blood Urea Nitrogen (BUN) level of 22 mg/dL is within the normal range, which is typically between 7 and 20 mg/dL. This level does not indicate immediate concern and is not as critical as the elevated creatinine level¹.

A. The nurse observes the client using accessory muscles while breathing. B. The client is able to answer questions in full sentences. C. Lung auscultation demonstrates diminished breath sounds. D. The client appears restless and anxious when resting in bed.

Correct Answer is B

Explanation

Choice A Reason:

Using accessory muscles while breathing is a sign of respiratory distress and indicates that the client is working harder to breathe. This is not a desired outcome of treatment and suggests that the asthma exacerbation is not under control.

Choice B Reason:

The ability to answer questions in full sentences suggests that the client's airway is not severely obstructed, which is a positive sign of effective asthma treatment. When asthma is well-controlled, individuals should not experience significant shortness of breath that limits their ability to speak.

Choice C Reason:

Diminished breath sounds can be a sign of severe airway obstruction and are not indicative of effective asthma treatment. Ideally, lung auscultation should reveal clear breath sounds without wheezing, indicating good air movement throughout the lungs.

Choice D Reason:

Restlessness and anxiety can be symptoms of hypoxia, a condition where the body or a region of the body is deprived of adequate oxygen supply. This is not a sign of effective asthma treatment and may indicate that the client's asthma is not well-managed.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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