The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Drank a glass of water in the past 2 hours.

Reports left chest wall pain prior to admission.

Experiences facial swelling after eating crab.

Verbalizes a fear of being in a confined space.

Answer and Explanation

The Correct Answer is C

The correct answer is: C. Experiences facial swelling after eating crab.

Choice A Reason: Drinking a glass of water in the past 2 hours is not typically a concern unless the patient has been instructed to fast. For most cardiac catheterization procedures, patients are asked to fast for a certain period before the procedure to reduce the risk of aspiration. However, small sips of water may be allowed with medications.

Choice B Reason: While reports of left chest wall pain are clinically significant and warrant investigation, they are not as immediately concerning for the angioplasty procedure itself. Chest pain is a symptom that may have led to the decision to perform angioplasty but does not pose an immediate risk of complication during the procedure as an allergy might.

Choice C Reason: As previously mentioned, experiencing facial swelling after eating crab is indicative of a shellfish allergy. This is important because the contrast dye used in angioplasty may contain iodine, and patients with shellfish allergies could have an increased risk of an allergic reaction to the iodine in the dye. It is essential to explore this further to take necessary precautions, such as premedication with antihistamines or using a different contrast agent.

Choice D Reason: Verbalizing a fear of being in a confined space, or claustrophobia, is a psychological concern that should be addressed to ensure the patient’s comfort during the procedure. However, it does not pose a direct risk to the safety of the angioplasty procedure like an allergic reaction does. Managing patient anxiety is important, but it is not the most critical factor to explore prior to the procedure.

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Correct Answer is C

Explanation

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

A. Red blood cell count (RBC). B. Core body temperature. C. Swollen lymph nodes in the groin. D. Location of the initial intravenous (IV) site. E. White blood cell count (WBC).

Correct Answer is ["B","C","E"]

Explanation

A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.

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The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is C

Explanation

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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