The nurse is caring for a client who just returned to the nursing unit following a cardiac angiogram and stent insertion. Which action should the nurse implement first?

Provide education to the client about the procedure.

Assess vital signs and catheter insertion site.

Administer fluids to provide hydration.

Administer the prescribed dose of aspirin and metoprolol.

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing education to the client about the procedure is not the action that the nurse should implement first. This action is important, but not urgent. The nurse should prioritize the assessment and monitoring of the client's physical status and potential complications.

Choice B reason: Assessing vital signs and catheter insertion site is the action that the nurse should implement first. This action is essential to evaluate the client's hemodynamic stability and to detect any signs of bleeding, hematoma, infection, or vascular injury at the site of catheter insertion. The nurse should also check the peripheral pulses and sensation of the affected extremity.

Choice C reason: Administering fluids to provide hydration is not the action that the nurse should implement first. This action may be indicated to prevent contrast-induced nephropathy or dehydration, but it is not the priority. The nurse should first assess the client's fluid status and renal function before administering fluids.

Choice D reason: Administering the prescribed dose of aspirin and metoprolol is not the action that the nurse should implement first. This action may be indicated to prevent thrombosis or ischemia, but it is not the priority. The nurse should first assess the client's cardiac status and contraindications before administering these medications.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.

Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.

Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.

Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.

A. International normalized ratio 1.3 seconds B. Hemoglobin 14 g/dL C. Serum iron 150 mcg/dL D. Platelet count 250,000/mm3

Correct Answer is B

Explanation

Choice A reason: The international normalized ratio (INR) is a measure of the blood's ability to clot. It is not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of INR is 0.8 to 1.2 seconds.

Choice B reason: Hemoglobin is the protein in red blood cells that carries oxygen. It is the main indicator of anemia and the response to iron therapy. The normal range of hemoglobin for adults is 12 to 18 g/dL. A hemoglobin level of 14 g/dL suggests that the patient's anemia has improved with ferrous sulfate therapy.

Choice C reason: Serum iron is the amount of iron in the blood. It is not a reliable indicator of anemia or iron therapy, as it can fluctuate with dietary intake, infection, inflammation, and other factors. The normal range of serum iron for adults is 50 to 170 mcg/dL.

Choice D reason: Platelet count is the number of platelets in the blood. Platelets are involved in blood clotting and wound healing. They are not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of platelet count for adults is 150,000 to 450,000/mm3.

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The nurse is caring for a client who just returned to the nursing unit following a cardiac angiogram and stent insertion. Which action should the nurse implement first?

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