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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The information that the nurse should include in the teaching plan for a client with hypertension who is on alpha blockers and at risk for postural hypotension is: Change positions slowly.
Alpha blockers are a class of medications commonly prescribed for hypertension. One potential side effect of alpha blockers is postural hypotension, which is a sudden drop in blood pressure when changing positions, such as from sitting to standing. To minimize the risk of postural hypotension, it is important for the client to change positions slowly. The nurse should advise the client to take their time when transitioning from lying down, sitting, or standing, allowing their body to adjust and stabilize their blood pressure.
The other options are not appropriate or helpful in managing postural hypotension:
Check blood pressure every day for signs of rebound hypertension: Rebound hypertension refers to a sudden increase in blood pressure that can occur when discontinuing certain antihypertensive medications. It is not directly related to postural hypotension. Regular blood pressure monitoring is important for managing hypertension, but it is not specifically related to postural hypotension or alpha blockers.
Do not become dependent on canes, walkers, or handrails: Assistive devices like canes, walkers, or handrails can provide support and stability for individuals who experience balance issues or are at risk of falls. It is not necessary to discourage their use unless there are specific contraindications or safety concerns.
Eat plenty of salty food to prevent hypotension: Increasing salt intake is generally not recommended for individuals with hypertension or those at risk of postural hypotension. A high-sodium diet can contribute to elevated blood pressure and is generally discouraged. The nurse should instead encourage a balanced diet that includes appropriate sodium intake based on the client's healthcare provider's recommendations.
Correct Answer is D
Explanation
The nurse should prioritize notifying the surgeon and anesthesiologist as the first action. The absent pulses, coolness, and mottled appearance of the leg indicate potential compromised blood flow to the lower extremity, which could be a sign of vascular compromise or acute limb ischemia. These findings are concerning after the repair of an abdominal aortic aneurysm and require immediate medical attention.
Wrap both legs in a warming blanket: While it is important to maintain the client's body temperature, this action alone may not address the underlying issue of compromised blood flow and potential limb ischemia. Notifying the surgeon and anesthesiologist is the priority to address the immediate concern.
Compare findings to the preoperative assessment of the pulses: While comparing findings to the preoperative assessment is important for evaluating the client's condition, it should not delay immediate action. The priority in this situation is to promptly notify the surgeon and anesthesiologist to address the potential vascular compromise.
Document the findings and recheck in 15 minutes: Documenting the findings is an important step in the nursing process, but it should not take precedence over immediate intervention. The concerning signs of absent pulses, coolness, and mottled appearance require urgent attention, and delaying notification could lead to further complications.
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