The nurse is giving instructions to a client having pulmonary angiography. Which of the following statements is the best evidence that the client understands what will take place during the diagnostic procedure? (Select all that apply.)
“I may feel some pressure at the site.”
“I may have bleeding at the site following the procedure.”
“I will be able to go to the bathroom when I return from the test.”
“I will sense a warm, flushed feeling and an urge to cough when the dye is injected.”
Correct Answer : A,B,D
A client who understands the pulmonary angiography procedure recognizes that pressure and mild bleeding can occur at the catheter insertion site and that a warm, flushed feeling and urge to cough may be experienced when the contrast dye is injected. These are expected responses and indicate an accurate understanding of the procedure and its sensations.
Rationale for correct answers:
1. “I may feel some pressure at the site.” During pulmonary angiography, a catheter is inserted—usually into the femoral vein—and guided into the pulmonary artery. The client may feel mild pressure or discomfort at the insertion site, which is normal and indicates proper procedural awareness.
2. “I may have bleeding at the site following the procedure.” After the procedure, minor bleeding or oozing at the insertion site can occur due to vascular puncture. The nurse must apply pressure and monitor the site for hematoma formation. Recognizing this possibility demonstrates that the client understands a potential post-procedure concern.
4. “I will sense a warm, flushed feeling and an urge to cough when the dye is injected.” The contrast dye used during angiography often causes transient sensations such as warmth, flushing, or a brief urge to cough. These are expected physiological reactions to the contrast medium and are not harmful. The client’s acknowledgment of this indicates appropriate preparation and understanding.
Rationale for incorrect answer:
3. “I will be able to go to the bathroom when I return from the test.” After pulmonary angiography, the client is usually placed on bed rest for several hours to prevent bleeding from the catheter insertion site. Movement, including getting up to use the bathroom, is restricted until the insertion site is stable and vital signs are normal. This statement demonstrates a misunderstanding of post-procedure care.
Take-home points:
- Pressure, minor bleeding, and warmth from dye injection are normal experiences during pulmonary angiography.
- Clients should remain on bed rest after the procedure to prevent bleeding at the insertion site.
- Educating the client on expected sensations and post-procedure precautions promotes comfort, safety, and cooperation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A low pulse oximetry reading may occur due to factors that interfere with accurate detection of oxygen saturation, such as nail polish, inadequate peripheral circulation, and edema. These conditions can prevent the oximeter’s light sensor from properly detecting arterial oxygen levels, leading to falsely low readings even when the patient’s oxygenation is normal.
Rationale for correct answers:
1. Nail polish. Dark-colored nail polish or artificial nails can block or distort the light signal used by the pulse oximeter, resulting in inaccurate or falsely low readings. The nurse should remove nail polish or use an alternate sensor site, such as the earlobe or toe, to obtain a reliable measurement.
2. Inadequate peripheral circulation. Poor blood flow, as seen in hypotension, hypothermia, or peripheral vascular disease, reduces the pulsatile flow required for accurate pulse oximetry readings. This can cause the device to register a lower saturation level than the actual arterial oxygen concentration.
5. Edema. Tissue swelling, especially in the fingers, interferes with the light transmission and absorption used by the oximeter. This results in unreliable or falsely low readings because the sensor cannot effectively detect the pulsating arterial blood.
Rationale for incorrect answers:
3. Hyperthermia. Elevated body temperature typically increases peripheral circulation and does not contribute to a low oxygen saturation reading. In some cases, it may even improve signal accuracy.
4. Increased hemoglobin (Hgb) level. A higher hemoglobin concentration enhances the blood’s oxygen-carrying capacity and does not lower pulse oximetry readings. In fact, pulse oximetry measures the percentage of hemoglobin saturated with oxygen, not the total hemoglobin level.
Take-home points:
- Nail polish, poor circulation, and edema can lead to falsely low pulse oximetry readings.
- Always verify low readings by reassessing with a clean, well-perfused site or using arterial blood gases (ABGs) for accuracy.
- Pulse oximetry readings should always be interpreted in conjunction with the patient’s overall clinical presentation.
Correct Answer is C
Explanation
Pulse oximetry may not be a reliable indicator of oxygen saturation in a patient in hypovolemic shock, because this condition leads to severely reduced blood volume and peripheral perfusion. When there is inadequate circulation to the extremities, the pulse oximeter cannot detect strong pulsatile blood flow, resulting in inaccurate or falsely low readings. Poor perfusion interferes with the sensor’s ability to measure oxygen saturation correctly, making the results unreliable for assessing true arterial oxygenation.
Rationale for correct answer:
3. Patient in hypovolemic shock. In hypovolemic shock, severe fluid loss decreases circulating blood volume and compromises peripheral circulation. Because pulse oximeters rely on detecting pulsatile arterial blood flow, poor perfusion produces erratic or inaccurate oxygen saturation readings. Therefore, SpO₂ results should be interpreted cautiously, and arterial blood gases (ABGs) may be required for accurate assessment.
Rationale for incorrect answers:
1. Patient with a fever. Fever increases oxygen demand but does not affect pulse oximeter accuracy as long as perfusion is adequate.
2. Patient who is anesthetized. Pulse oximetry remains accurate during anesthesia with proper probe placement and perfusion.
4. Patient receiving oxygen therapy. Oxygen therapy raises SpO₂ but does not make readings unreliable; values still reflect actual oxygen saturation.
Take-home points:
- Pulse oximetry requires adequate perfusion and pulsatile flow for accuracy.
- Conditions like shock, hypothermia, or vasoconstriction may cause false or low readings.
- In hypovolemia, ABG analysis offers a more precise measure of oxygenation.
- Always interpret SpO₂ in context with the patient’s clinical condition and perfusion status.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.