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","B","D","F"]
Explanation
The correct answer is choice A, B, D, and F.
Choice A rationale:
The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.
Choice B rationale:
The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.
Choice C rationale:
The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.
Choice D rationale:
The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.
Choice E rationale:
The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.
Choice F rationale:
The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.
Choice G rationale:
The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.
Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.
Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.
Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.
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