The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?

2+ bilateral peripheral edema

Heart rate 59 beats/min

Temperature of 96 F

Muffled heart sounds

Answer and Explanation

The Correct Answer is D

A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.

B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.

C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.

D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.

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Correct Answer is B

Explanation

A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.

B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.

C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.

D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.

A. Increase IV fluid infusion per protocol. B. Lower the head of the clients bed in Trendelenburg position C. Document CVP and continue to monitor. D. Administer IV diuretic medications.

Correct Answer is D

Explanation

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

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The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?

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