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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A drop in diastolic blood pressure (25 mmHg) upon rising: Orthostatic (postural) hypotension is diagnosed by a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing. A 25 mmHg drop in diastolic pressure is a significant change and meets criteria for this condition.
B. A pulsating headache: While a headache may accompany blood pressure fluctuations, it is not a defining symptom of postural hypotension. It lacks the diagnostic specificity needed to confirm this condition.
C. A blood pressure elevation upon activity: An increase in blood pressure during activity is expected and not diagnostic of postural hypotension. In fact, postural hypotension involves a blood pressure drop upon standing, not a rise.
D. A drop in systolic blood pressure (15 mm Hg) upon rising: A 15 mmHg systolic drop does not meet the threshold for orthostatic hypotension. For diagnosis, the systolic pressure must drop by at least 20 mmHg within 3 minutes of standing.

A. Dyspnea when ambulating from the bathroom B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration C. Pulsus paradoxus on vital sign assessment D. Cyanosis with a pulse oximetry level of 92%

Correct Answer is C

Explanation

A. Dyspnea when ambulating from the bathroom: Mild exertional dyspnea is common in cardiac clients and may not require immediate provider notification unless it worsens or becomes unrelieved with rest.
B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration: An irregular pulse may warrant holding the medication and further assessment, but it is not always an emergency unless associated with hemodynamic instability or bradycardia.
C. Pulsus paradoxus on vital sign assessment: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, may indicate cardiac tamponade or severe pericardial effusion. It is a critical finding that requires immediate medical attention.
D. Cyanosis with a pulse oximetry level of 92%: While cyanosis is concerning, a SpO₂ of 92% may be acceptable for some cardiac or pulmonary patients. Further monitoring is needed, but it may not require urgent notification unless oxygen levels drop further.

View Question and Answer

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

The nurse provides care for a post-cardiac catheterization male client in the postprocedure room. Which is a priority nursing action for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

Correct Answer is A

Explanation

The nurse is caring for clients on a busy cardiac unit. Following morning assessment, the nurse would notify the physician with which of the following symptoms?

Correct Answer is C

Explanation

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?

A client who is a nursing student reports increased anxiety with test taking. Which behavioral technique is most appropriate for this client to put into practice?

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

During a multidisciplinary meeting, the group discussed potential signs of tardive dyskinesia noted sporadically in a client. Following the meeting, symptoms progressed for the client. Which medical order does the nurse anticipate?

The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the appropriate action by the nurse?

The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?