The nurse has obtained assessment data for a client who is scheduled for a cardiac angiogram (catheterization). Which information must the nurse report to the health care provider prior to the procedure?

Admission blood pressure is 110/70.

Client has multiple food and drug allergies.

Pedal pulses are 1+ bilaterally.

Client is slightly anxious.

Answer and Explanation

The Correct Answer is B

Choice A reason: Admission blood pressure is 110/70 is not the information that the nurse must report to the health care provider prior to the procedure. This is a normal blood pressure reading for an adult client and does not indicate any contraindication or complication for the cardiac angiogram.

Choice B reason: Client has multiple food and drug allergies is the information that the nurse must report to the health care provider prior to the procedure. This is a critical information that may affect the choice of contrast agent, medications, or equipment used for the cardiac angiogram. The nurse should identify the specific allergens and the type and severity of the allergic reactions that the client has experienced in the past.

Choice C reason: Pedal pulses are 1+ bilaterally is not the information that the nurse must report to the health care provider prior to the procedure. This is a low-normal finding for the strength of the peripheral pulses and does not indicate any significant vascular impairment or obstruction. The nurse should document and monitor the pedal pulses, but not necessarily report them.

Choice D reason: Client is slightly anxious is not the information that the nurse must report to the health care provider prior to the procedure. This is a common and expected emotional response for a client who is undergoing an invasive diagnostic test and does not require any immediate intervention. The nurse should provide reassurance and education to the client and address any concerns or questions that they may have.

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Correct Answer is D

Explanation

Choice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

A. International normalized ratio 1.3 seconds B. Hemoglobin 14 g/dL C. Serum iron 150 mcg/dL D. Platelet count 250,000/mm3

Correct Answer is B

Explanation

Choice A reason: The international normalized ratio (INR) is a measure of the blood's ability to clot. It is not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of INR is 0.8 to 1.2 seconds.

Choice B reason: Hemoglobin is the protein in red blood cells that carries oxygen. It is the main indicator of anemia and the response to iron therapy. The normal range of hemoglobin for adults is 12 to 18 g/dL. A hemoglobin level of 14 g/dL suggests that the patient's anemia has improved with ferrous sulfate therapy.

Choice C reason: Serum iron is the amount of iron in the blood. It is not a reliable indicator of anemia or iron therapy, as it can fluctuate with dietary intake, infection, inflammation, and other factors. The normal range of serum iron for adults is 50 to 170 mcg/dL.

Choice D reason: Platelet count is the number of platelets in the blood. Platelets are involved in blood clotting and wound healing. They are not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of platelet count for adults is 150,000 to 450,000/mm3.

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The nurse has obtained assessment data for a client who is scheduled for a cardiac angiogram (catheterization). Which information must the nurse report to the health care provider prior to the procedure?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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