A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

Instruct the client to drink 1 L of water before the test.

Administer intravenous (IV) benzodiazepines and opioids.

Inform the client that the client will remain on bed rest following the procedure

Inform the client that an access line will be initiated in the femoral artery.

Answer and Explanation

The Correct Answer is D

Transesophageal echocardiography is a diagnostic procedure that involves inserting a probe into the esophagus to obtain detailed images of the heart. In some cases, an access line may be initiated in the femoral artery to monitor blood pressure during the procedure and administer medications if needed. Informing the client about this aspect of the procedure helps ensure that they are aware of what to expect and can provide informed consent.

Let's go through the other options and explain why they are not the most appropriate actions:

Instruct the client to drink 1 L of water before the test: This action is not necessary for transesophageal echocardiography. Drinking water before the test is typically done for certain abdominal or pelvic ultrasound examinations to provide better visualization. However, for TEE, the probe is inserted into the esophagus, and drinking water is not required.

Administer intravenous (IV) benzodiazepines and opioids: The administration of intravenous benzodiazepines and opioids is not a routine part of preparing a client for TEE. The need for sedation or analgesia during the procedure would be determined based on the individual client's condition and level of discomfort.

Inform the client that the client will remain on bed rest following the procedure: While some post-procedure instructions may be given to the client, such as avoiding eating or drinking until the effects of sedation wear off, informing the client that they will remain on bed rest following the procedure is not a speciﬁc requirement for TEE. Post-procedure instructions can vary depending on the individual client's condition and the healthcare provider's recommendations.

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 C

Explanation

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

A. A client with a blood pressure of 190/92 mm Hg who reports chest pain B. A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia C. A client with a blood pressure of 178/90 mm Hg who has intermittent claudication D. A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Correct Answer is A

Explanation

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

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

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Correct Answer is C

Explanation

The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

Correct Answer is A

Explanation

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?

The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

The nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

The nurse is teaching a client with atrial ﬂutter who is scheduled for a catheter ablation? What should the nurse include in the teaching plan?