A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

Draw blood specimens for culture and sensitivity.

Administer nitroglycerin 0.4 mg SL 30 min before the procedure.

Obtain a CBC with differential.

Transport the client to radiology for a CT scan.

Answer and Explanation

The Correct Answer is C

A. Draw blood specimens for culture and sensitivity: Incorrect. Blood cultures are not routinely required for cardiac catheterization.

B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure: Incorrect. Nitroglycerin is not typically administered before a cardiac catheterization unless specifically ordered.

C. Obtain a CBC with differential: A complete blood count (CBC) is necessary before a cardiac catheterization to assess for potential bleeding risks, infection, or anemia.

D. Transport the client to radiology for a CT scan: Incorrect. Cardiac catheterization is performed in a specialized cardiac catheterization lab, not in radiology.

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Correct Answer is ["A","C","D","F"]

Explanation

A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.

B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.

C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.

D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.

E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.

F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.

A. "I know that I will be reunited with my child someday." B. "I am unable to feel any joy since my child died." C. "I feel guilty because my child died." D. "I am angry that my child died."

Correct Answer is B

Explanation

A. Belief in being reunited with the child is a common and healthy coping mechanism.

B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.

C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.

D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.

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A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

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