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.
Obtain a CBC with differential.
Transport the client to radiology for a CT scan.
Administer nitroglycerin 0.4 mg SL 30 min before the procedure.
The Correct Answer is B
The correct answer is choice b. Obtain a CBC with differential.
Choice A rationale:
Drawing blood specimens for culture and sensitivity is not typically required before a cardiac catheterization unless there is a specific concern about infection.
Choice B rationale:
Obtaining a CBC with differential is important to assess the client’s overall health and detect any potential issues such as anemia or infection that could complicate the procedure.
Choice C rationale:
Transporting the client to radiology for a CT scan is not a standard pre-procedure task for cardiac catheterization. This might be necessary if there are specific indications, but it is not routine.
Choice D rationale:
Administering nitroglycerin 0.4 mg SL 30 minutes before the procedure is not a standard practice for preparing a client for cardiac catheterization. Nitroglycerin is typically used to manage chest pain or angina, not as a pre-procedure medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.
Choice B rationale:
Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.
Choice C rationale:
Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.
Choice D rationale:
Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.
Correct Answer is D
Explanation
Choice A rationale:
Expecting to have a rapid pulse rate for the first few weeks is not accurate information for a client with a newly implanted implantable cardioverter-defibrillator (ICD). After the ICD placement, the client's heart rate should stabilize within normal ranges. A consistently rapid pulse rate might indicate an issue with the device or the client's cardiovascular system, necessitating further evaluation.
Choice B rationale:
Returning in two weeks for a follow-up MRI is not advisable immediately after ICD placement. MRI (Magnetic Resonance Imaging) is contraindicated for individuals with ICDs due to the magnetic fields, which can interfere with the functioning of the device. The timing and necessity of any future MRI should be carefully planned and discussed with the healthcare provider in charge of the client's care.
Choice C rationale:
Resuming tub baths and swimming after 24 hours is not recommended after ICD placement. Submerging the ICD site in water, especially in the initial healing phase, can increase the risk of infection. Clients with newly implanted ICDs are usually advised to avoid submerging the device site in water for a specified period, as recommended by their healthcare provider.
Choice D rationale:
Wearing loose-fitting clothing is important advice for clients with newly implanted ICDs. Tight clothing, especially around the site of the device, can cause irritation and discomfort. Loose-fitting clothing ensures proper airflow to the site, reducing the risk of irritation and allowing for optimal healing. It is essential to provide this information to the client to promote comfort and prevent complications related to the ICD placement.
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