A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

"You should expect to feel some tingling in the affected limb the day following the procedure."

"You might be asked to perform mild exercises during the procedure."

"You should not eat or drink for 4 hr following the procedure."

"You might have to lie in bed for 6 hr after the procedure."

Answer and Explanation

The Correct Answer is D

A. "You should expect to feel some tingling in the affected limb the day following the procedure." Tingling in the limb could indicate nerve or circulatory problems and should be reported immediately. It is not a normal post-procedure expectation.

B. "You might be asked to perform mild exercises during the procedure." Clients are typically instructed to remain still during a cardiac catheterization to avoid complications at the insertion site. Mild exercises are not a part of the procedure.

C. "You should not eat or drink for 4 hr following the procedure." NPO (nothing by mouth) status is usually required before the procedure, not after. Clients are encouraged to drink fluids after the procedure to help flush the contrast dye from their system.

D. "You might have to lie in bed for 6 hr after the procedure." After a cardiac catheterization, especially with a femoral artery approach, clients may be required to remain on bed rest for 4-6 hours to prevent bleeding or complications at the catheter insertion site.

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Correct Answer is D

Explanation

A. "A heart murmur is a high-pitched sound due to a narrow valve." While some murmurs may be caused by a narrow valve (stenosis), not all murmurs are high-pitched. Murmurs vary in pitch depending on the cause, so this is not a comprehensive explanation.

B. "A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber." This describes an S3 or S4 sound rather than a murmur. A heart murmur is typically related to turbulent blood flow through valves, not just an inflexible heart chamber.

C. "This means that there is some inflammation around your heart." This statement incorrectly links a murmur to pericarditis or myocarditis, which involve inflammation. A murmur is associated with abnormal blood flow, not inflammation.

D. "This indicates turbulent (chaotic, random fluctuations) blood flow through a valve." A heart murmur is caused by turbulent blood flow, which can occur when blood moves through a valve that is narrow or has regurgitation. This is the correct explanation.

A. Reassuring the partner of a client who sustained a closed head injury B. Collecting data from a client who reports unilateral calf pain when ambulating C. Taking a telephone prescription for a client who is to be transferred from PACU D. Reinforcing a client's dressing on an above-the-knee amputation surgical site

Correct Answer is B

Explanation

A. Reassuring the partner of a client who sustained a closed head injury: While providing emotional support to family members is important, this is not the first priority. The immediate concern should be a potential physical complication in a client.

B. Collecting data from a client who reports unilateral calf pain when ambulating: Unilateral calf pain can indicate deep vein thrombosis (DVT), which can lead to a pulmonary embolism if left untreated. This is the most urgent situation and requires immediate assessment.

C. Taking a telephone prescription for a client who is to be transferred from PACU: While transferring a client requires coordination, it is not as urgent as assessing for potential life-threatening complications, such as DVT.

D. Reinforcing a client's dressing on an above-the-knee amputation surgical site: While it is important to manage the surgical site, the client with potential DVT requires more immediate attention due to the risk of pulmonary embolism.

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A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

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