The nurse provides care for a post-cardiac catheterization male client in the postprocedure room. Which is a priority nursing action for this client?
Advise the client to void while lying flat with a urinal.
Encourage the client to drink fluids.
Evaluate the client's temperature.
Monitor the client's pressure dressing.
The Correct Answer is D
A. Advise the client to void while lying flat with a urinal: While voiding in a supine position is often necessary to maintain hemostasis, it is not the top priority. It is a supportive measure that follows after ensuring vascular integrity.
B. Encourage the client to drink fluids: Hydration helps flush contrast dye from the kidneys and is important, but it is a secondary priority. Bleeding at the catheter insertion site requires more immediate attention post-procedure.
C. Evaluate the client's temperature: Monitoring temperature may detect late signs of infection, but it is not a critical concern in the immediate post-catheterization period unless there are signs of systemic illness.
D. Monitor the client's pressure dressing: Bleeding or hematoma formation at the catheter insertion site (often the femoral artery) is a major concern. Frequent monitoring of the pressure dressing is essential to detect and manage hemorrhage early, making it the top priority.
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Related Questions
Correct Answer is D
Explanation
A. Hydroxyurea: Hydroxyurea is a chemotherapeutic agent primarily used in conditions like sickle cell disease and some cancers. It is not part of standard antiretroviral therapy (ART) for HIV management.
B. Anticholinergics: Anticholinergics are used to reduce secretions or treat conditions like asthma and overactive bladder. They are not used in the treatment of HIV and do not affect viral replication.
C. Disinhibitors: "Disinhibitors" is not a recognized pharmacological class in the treatment of HIV. The term "disinhibitor" might be used in other contexts, such as describing the effects of certain substances on behavior, but it's not a pharmacological classification for HIV medications.
D. Reverse transcriptase inhibitors: These are a cornerstone of HIV treatment. They inhibit the reverse transcriptase enzyme, which the virus uses to convert its RNA into DNA. This class includes both NRTIs and NNRTIs and is typically used in combination therapy.
Correct Answer is A
Explanation
A. Fever, sore throat, and chills: These are classic signs of infection and are especially concerning in leukopenia, where the body’s ability to fight infections is compromised due to a low white blood cell count. Prompt recognition is critical for early intervention.
B. Nausea and vomiting: While these may be side effects of many medications, they are not specific indicators of leukopenia. They reflect gastrointestinal irritation rather than immunosuppression.
C. Intolerance to heat and rash: These symptoms are more consistent with thyroid dysfunction or allergic reactions, not leukopenia. They do not suggest a compromised immune response.
D. Diarrhea, diaphoresis, and fever: Though fever can be a sign of leukopenia-related infection, diarrhea and diaphoresis are nonspecific symptoms and may relate to other systems or drug side effects. Fever, sore throat, and chills are more indicative of infection due to leukopenia.
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