A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?

Encourage the client to ambulate within 30 min following the procedure.

Keep the client NPO for at least 2 hr following the procedure.

Assess pulses in the client's affected arm.

Apply light pressure to the insertion site.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.

Choice B rationale

Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.

Choice C rationale

Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.

Choice D rationale

Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .

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Correct Answer is []

Explanation

Condition: Myocardial infarction.

2 actions:

Administer oxygen via nasal cannula 2 L/min,

Request a prescription for aspirin 325 mg.

2 parameters:

Vital signs,

Electrocardiogram (ECG) rhythm.

Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.

Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.

Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.

A. Reduced bronchospasm. B. Decreased breathlessness. C. Increased carbon dioxide retention. D. Improved oxygen saturation levels.

Correct Answer is D

Explanation

Choice A rationale

Reduced bronchospasm is a beneficial outcome for COPD, but it is not the primary outcome related to gas exchange.

Choice B rationale

Decreased breathlessness is a positive outcome for COPD, but it is not directly related to gas exchange.

Choice C rationale

Increased carbon dioxide retention is a negative outcome and indicates worsening of gas exchange.

Choice D rationale

Improved oxygen saturation levels are a direct and measurable outcome of effective gas exchange and indicate better oxygenation in COPD patients.

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A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Which outcome is appropriate for the client problem of "ineffective gas exchange" for the client diagnosed with chronic obstructive pulmonary disease (COPD)?

Correct Answer is D

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A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?