The nurse is caring for a client who just returned to the nursing unit following a cardiac angiogram and stent insertion. Which action should the nurse implement first?
Provide education to the client about the procedure.
Assess vital signs and catheter insertion site.
Administer fluids to provide hydration.
Administer the prescribed dose of aspirin and metoprolol.
The Correct Answer is B
Choice A reason: Providing education to the client about the procedure is not the action that the nurse should implement first. This action is important, but not urgent. The nurse should prioritize the assessment and monitoring of the client's physical status and potential complications.
Choice B reason: Assessing vital signs and catheter insertion site is the action that the nurse should implement first. This action is essential to evaluate the client's hemodynamic stability and to detect any signs of bleeding, hematoma, infection, or vascular injury at the site of catheter insertion. The nurse should also check the peripheral pulses and sensation of the affected extremity.
Choice C reason: Administering fluids to provide hydration is not the action that the nurse should implement first. This action may be indicated to prevent contrast-induced nephropathy or dehydration, but it is not the priority. The nurse should first assess the client's fluid status and renal function before administering fluids.
Choice D reason: Administering the prescribed dose of aspirin and metoprolol is not the action that the nurse should implement first. This action may be indicated to prevent thrombosis or ischemia, but it is not the priority. The nurse should first assess the client's cardiac status and contraindications before administering these medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Avoiding strenuous activity and standing up slowly is not a relevant response to the client's complaint of headache. These actions may help prevent or reduce orthostatic hypotension, which is another possible side effect of nitroglycerin, but not headache.
Choice B reason: Headache is expected and should subside with continued use is a correct and appropriate response to the client's complaint of headache. The nurse should explain that headache is a common and transient side effect of nitroglycerin, which is caused by the vasodilation effect of the drug. The nurse should also advise the client to take over-the-counter analgesics, such as acetaminophen, to relieve the headache.
Choice C reason: Reducing the dosage to help relieve this side effect is not a correct or appropriate response to the client's complaint of headache. The nurse should not suggest any changes in the prescribed dosage of nitroglycerin, as this may compromise the effectiveness of the drug and increase the risk of angina or myocardial infarction. The nurse should also remind the client to follow the instructions for applying and removing the Nitropatch.
Choice D reason: You will have this side effect as long as you are taking nitroglycerin is not a correct or appropriate response to the client's complaint of headache. The nurse should not discourage or alarm the client by implying that the headache is inevitable and permanent. The nurse should reassure the client that the headache will likely diminish over time as the body adapts to the drug.
Correct Answer is C
Explanation
Choice A reason: You feel good because your medication is working properly is not the most appropriate statement by the nurse. This statement may imply that the client does not need to worry about their blood pressure or follow up with their doctor. The nurse should educate the client about the importance of regular monitoring and adherence to the prescribed treatment.
Choice B reason: Your blood pressure reflects how strong your heart muscle contracts is not the most appropriate statement by the nurse. This statement may confuse the client or give them a false sense of security. The nurse should explain that blood pressure is determined by the force and amount of blood pumped by the heart and the resistance of the blood vessels. The nurse should also inform the client about the normal and abnormal ranges of blood pressure and the risk factors for hypertension.
Choice C reason: Even if you are feeling good, damage can occur to your heart and kidneys is the most appropriate statement by the nurse. This statement conveys the seriousness of hypertension and its potential complications. The nurse should educate the client about the effects of high blood pressure on the vital organs and the need for preventive measures and lifestyle modifications.
Choice D reason: Have you told your doctor that you are feeling good is not the most appropriate statement by the nurse. This statement may suggest that the nurse is not interested in the client's condition or does not have the knowledge or authority to address their concerns. The nurse should communicate effectively with the client and the health care team and provide appropriate guidance and support.
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