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.

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Correct Answer is B

Explanation

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

A. Obtain consent for transesophageal echocardiogram (TEE) B. Obtain consent for a STAT defibrillation C. Obtain consent for cardioversion. D. Hold digoxin 48 hours prior to cardioversion.

Correct Answer is B

Explanation

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

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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 caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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