Review Practice Exercise 3

Cardiovascular Diagnostic and Therapeutic Procedures > Adult Health/Med Surg

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Practice Exercise 3

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Total Questions : 10

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Question 1:

A client returns to the medical unit 30 minutes after undergoing coronary angiography via the femoral artery. During assessment, the nurse notes a rapidly enlarging hematoma at the puncture site. Which nursing action is the priority?

A. Apply firm manual pressure over the insertion site. B. Elevate the affected extremity above the level of the heart. C. Encourage the client to flex the affected leg. D. Document the finding and reassess in 15 minutes.

Answer and Explanation

Choice A:

Applying firm manual pressure over the insertion site is the priority nursing action. Direct compression provides the immediate counter-pressure needed to override the high hydrostatic pressure of the femoral artery, mechanically halting the active bleeding. The nurse must hold continuous, firm pressure at or slightly proximal to the skin puncture site for at least 15 to 20 minutes to achieve hemodynamic hematoma stabilization. This immediate physical intervention takes precedence over all other diagnostic or reporting steps.

Choice B:

Elevating the affected extremity above the level of the heart is an incorrect action that can worsen the bleeding. Raising the leg forces the hip joint to flex, which kinks the femoral access sheath or tract, increasing intraluminal arterial shear stress. Furthermore, lifting the leg alters local structural alignments, allowing blood to track more freely into the retroperitoneal cavity and potentially causing hidden hypovolemic shock.

Choice C:

Encouraging the client to flex the affected leg is strictly contraindicated after femoral arterial access. Post-procedure protocols require the client to keep the affected extremity perfectly straight to preserve structural closure at the arteriotomy tract. Flexing the leg increases intra-abdominal pressure and disrupts early clot formation, directly causing catastrophic arterial tract rupture.

Choice D:

Documenting the finding and reassessing in 15 minutes is a dangerous action that allows severe, unchecked hemorrhage to progress. A rapidly expanding hematoma can cause acute compartment syndrome or lead to massive, life-threatening blood loss within a few minutes. Deferring care for 15 minutes violates basic patient safety preservation guidelines. Active arterial bleeding demands an immediate, hands-on physical response.

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Question 2:

A client is scheduled for coronary angiography with iodinated contrast. Which laboratory value is the nurse's highest priority to review before the procedure?

A. White blood cell count B. Hemoglobin C. Serum creatinine D. Serum potassium

Answer and Explanation

Choice A:

The white blood cell count is a routine laboratory value that tracks immune status and active inflammatory responses but is not a priority for contrast administration. While an elevated count can point toward an underlying infection, it has no bearing on the risk of developing contrast-induced renal injury. This value does not influence the choice, volume, or delivery speed of the iodinated agent, making it a secondary clinical consideration.

Choice B:

The hemoglobin level evaluates oxygen-carrying capacity and baseline systemic anemia but does not take priority over renal parameters before angiography. Although significant anemia can worsen myocardial ischemia during the stress of a cardiac catheterization, it does not correlate with nephrotoxic contrast vulnerabilities. This marker is monitored to establish a baseline in case post-procedure bleeding occurs, rather than to prevent acute organ toxicity.

Choice C:

Serum creatinine is the highest-priority laboratory value to review before a contrast-medium procedure. Serum creatinine provides a reliable estimation of the baseline glomerular filtration rate, allowing the clinician to screen for pre-existing renal functional impairment. Patients with elevated baseline creatinine require aggressive pre-procedure prophylactic interventions, such as tailored intravenous hydration with normal saline or sodium bicarbonate, to protect functional nephron architecture.

Choice D:

The serum potassium level is crucial for tracking cardiac electrical stability but is not the primary marker tied to contrast safety. While severe hyperkalemia or hypokalemia can trigger dangerous arrhythmias during intracardiac catheter manipulation, potassium levels do not dictate contrast clearance capacities. Renal filtration function must take priority because failing to identify renal impairment can lead to post-procedure metabolic disturbances and permanent kidney failure.

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Question 3:

The nurse is preparing a client for coronary angiography. Which nursing interventions are appropriate before the procedure? Select all that apply

A. Verify informed consent has been obtained. B. Assess for allergies to contrast media. C. Assess peripheral pulses and mark their locations. D. Review baseline renal function. E. Encourage the client to consume a large meal before the procedure. F. Establish intravenous access.

Answer and Explanation

Choice A:

Verifying that informed consent has been obtained is a mandatory legal and ethical intervention that must occur before any invasive procedure. The nurse must ensure the provider has explained the risks, benefits, and alternatives of the angiography and that the signed document is present in the medical record. This verification preserves patient legal autonomy and satisfies institutional safety standards.

Choice B:

Assessing for allergies to contrast media is an essential screening measure to prevent life-threatening anaphylactoid systemic reactions. Because coronary angiography utilizes high-volume iodinated contrast, individuals with known hypersensitivity require pre-medication regimens using corticosteroids and antihistamines. Identifying these risks early allows the care team to implement prophylactic safety protocols.

Choice C:

Assessing peripheral pulses and marking their locations with a surgical marker is a vital nursing intervention. Establishing a clear baseline of distal pulse strength (such as the dorsalis pedis and posterior tibial pulses) allows for accurate comparison after the procedure. This pre-mapping ensures the rapid detection of acute arterial occlusion or hematoma-induced compression along the accessed femoral or radial track.

Choice D:

Reviewing baseline renal function via serum creatinine and blood urea nitrogen levels is a high-priority safety step. Iodinated contrast carries a significant risk of causing contrast-induced nephropathy, especially in patients with pre-existing kidney disease. Reviewing these values allows the care team to initiate protective intravenous hydration protocols to preserve nephron architecture.

Choice E:

Encouraging the client to consume a large meal before the procedure is incorrect and dangerous. Patients are typically placed on NPO (nothing by mouth) status for 6 to 8 hours prior to angiography to reduce the risk of aspiration gastric pneumonitis. If the client develops contrast-induced nausea or an emergency arises requiring conscious sedation or general anesthesia, a full stomach increases the risk of fatal airway compromise.

Choice F:

Establishing reliable intravenous access is required to facilitate fluid administration and provide emergency medication delivery. Large-bore venous access ensures that pre-procedure hydration can be delivered smoothly to protect the kidneys. It also provides an immediate pathway for advanced cardiac life support medications if a malignant arrhythmia occurs during catheter manipulation.

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Question 4:

A client undergoes coronary angiography through the radial artery. Which post-procedure assessment finding requires immediate intervention?

A. Capillary refill less than 2 seconds B. Warm fingers with palpable radial pulse C. Increasing numbness and coolness of the hand D. Mild tenderness at the puncture site

Answer and Explanation

Choice A:

A capillary refill of less than 2 seconds is a normal, reassuring finding after a radial artery procedure. This rapid refill time confirms that microvascular tissue perfusion remains intact within the distal digits. It indicates that capillary beds are receiving adequate blood flow from the palmar arterial network, requiring no emergency clinical intervention.

Choice B:

Finding warm fingers with a palpable radial pulse is an expected, optimal outcome following radial access. These assessment signs demonstrate that the radial artery remains patent and is delivering adequate oxygenated blood flow to the hand. This profile shows that collateral circulation is functioning perfectly, confirming that the limb is safe from ischemic vascular complications.

Choice C:

Increasing numbness and coolness of the hand requires immediate intervention. These sensory and thermal changes are classic signs of acute limb ischemia and peripheral nerve compression. They indicate that blood flow through the radial artery, and potentially collateral flow from the ulnar artery, has been severely compromised. The nurse must immediately check for an expanding hematoma, release pressure if a pneumatic compression device is over-inflated, and alert the healthcare provider to perform emergent vascular evaluation.

Choice D:

Mild tenderness at the puncture site is an expected post-procedural finding that does not require emergency care. Navigating catheters through a peripheral artery causes minor localized endothelial tissue trauma and inflammation. As long as the pain remains mild, lacks a throbbing quality, and is not accompanied by an expanding mass, it is managed with routine observation protocols.

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Question 5:

The nurse is assessing a client four hours after femoral artery cardiac catheterization. Which finding requires immediate action?

A. Blood pressure of 126/74 mmHg B. Small amount of bruising at the insertion site C. Sudden onset of severe back pain with hypotension D. Mild discomfort when changing position

Answer and Explanation

Choice A:

A blood pressure of 126/74 mmHg is a stable, normal hemodynamic finding that indicates excellent systemic tissue perfusion. This pressure reading demonstrates that the client is maintaining adequate vascular volume and cardiac output following the procedure, requiring no emergency corrective actions.

Choice B:

A small amount of bruising at the insertion site is an expected, minor finding four hours after a femoral artery puncture. Navigating heavy-gauge catheters through the subcutaneous tissue causes baseline localized capillary tissue bleeding. As long as the bruised area remains small, flat, non-expanding, and lacks an active throbbing sensation, it is managed with routine nursing observation patterns.

Choice C:

A sudden onset of severe back pain with hypotension requires immediate action. These classic, co-occurring signs indicate a severe retroperitoneal hematoma complication caused by blood leaking upward from the femoral arteriotomy site into the retroperitoneal cavity. The accumulating blood puts mechanical pressure on local nerve structures and the lower spine, creating intense back or flank pain, while rapid blood loss causes hypovolemic circulatory shock. The nurse must immediately stop any active anticoagulant infusions, prepare for emergent fluid or blood resuscitation, and notify the healthcare provider to secure an urgent abdominal CT scan.

Choice D:

Mild discomfort when changing positions is a common, non-urgent reaction following prolonged bed rest and local tissue trauma. Post-procedure safety protocols require patients to remain flat and immobile for several hours to protect the arterial closure tract. This forced immobility can cause minor musculoskeletal stiffness and soreness that resolves with standard comfort interventions.

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Question 6:

The nurse is providing discharge teaching following coronary angiography. Which instructions should be included? Select all that apply

A. Limit fluid intake. B. Avoid strenuous activity and heavy lifting for the prescribed period. C. Report numbness, tingling, or coolness of the affected extremity. D. Expect continuous bleeding from the insertion site for several days. E. Inspect the puncture site daily for swelling or signs of infection.

Answer and Explanation

Choice A:

Limiting fluid intake is incorrect and counterproductive after a contrast-medium procedure. Patients are actively encouraged to increase their oral fluid intake to facilitate the rapid clearance of iodinated contrast from the bloodstream. Maintaining a high fluid volume promotes brisk urine output, which helps dilute the contrast agent within the renal tubules and lowers the risk of contrast-induced nephropathy. Fluid limits are only applied if the client has a history of severe, uncompensated advanced heart failure.

Choice B:

Avoiding strenuous activity and heavy lifting for the prescribed period is an essential safety instruction. The physical stress of heavy lifting or intense exertion increases intra-arterial shear forces and intra-abdominal pressure. This stress can easily disrupt the forming fibrin plug at the arteriotomy site, leading to a delayed arterial hemorrhage. Patients are typically advised to avoid lifting objects heavier than 5 to 10 pounds for several days to allow the puncture tract to heal completely.

Choice C:

Reporting numbness, tingling, or coolness of the affected extremity is a high-priority safety instruction. These sensory and thermal changes are classic indicators of acute peripheral nerve compression or arterial occlusion. They can be caused by a delayed clot forming inside the lumen or a hidden hematoma pressing on nearby nerves. Teaching the client to spot these signs early allows for quick medical intervention to prevent permanent neurovascular limb damage.

Choice D:

Expecting continuous bleeding from the insertion site for several days is an unsafe instruction that could lead to fatal delays in seeking emergency care. The puncture track must be completely sealed before discharge, and any active or recurring bleeding is abnormal. Continuous bleeding or oozing indicates a failure of the vascular closure mechanism and can quickly lead to a life-threatening hematoma formation. Patients must be taught to apply direct manual pressure and call emergency services immediately if bleeding recurs.

Choice E:

Inspecting the puncture site daily for swelling, redness, warmth, or drainage is necessary to detect localized complications early. A puncture track creates a direct pathway through the skin barrier, placing the patient at a baseline risk for delayed soft-tissue infection or localized hematoma development. Teaching patients to look for these changes daily ensures they can spot a problem and seek medical evaluation before a minor infection progresses to systemic sepsis.

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Question 7:

A client requires long-term intermittent chemotherapy expected to continue for the next 18 months. Which vascular access device is most appropriate?

A. Peripheral intravenous catheter B. Midline catheter C. Implanted port D. Butterfly needle

Answer and Explanation

Choice A:

A peripheral intravenous catheter is a short-term access device intended for brief therapies lasting less than a week. It is completely unsuited for an 18-month timeline because it requires frequent site rotations every few days, leading to severe venous scarring. Additionally, administering irritating vesicant chemotherapy into small peripheral veins carries an unacceptably high risk of chemical phlebitis and destructive deep tissue extravasation.

Choice B:

A midline catheter is a peripherally inserted device that terminates in the proximal upper arm, well before reaching the central venous circulation. Midlines are designed for intermediate therapies lasting between 1 and 4 weeks. Because they do not deliver medications into a high-flow central vein, they are not cleared for administering continuous vesicants or hypertonic solutions, making them inappropriate for long-term cytotoxic chemotherapy regimens.

Choice C:

An implanted port is the most appropriate vascular access device for long-term, intermittent treatment lasting 18 months. Because the port reservoir is anchored entirely under the subcutaneous tissue, it can remain safely in place for months or years. When chemotherapy is needed, the nurse accesses the port using a specialized non-coring (Huber) needle. When not in use, the skin remains intact, which drastically reduces the incidence of catheter-associated bloodstream infections and matches the intermittent nature of the treatment schedule.

Choice D:

A butterfly needle is a short, rigid steel needle with flexible plastic wings designed solely for immediate, single-use procedures like diagnostic venipuncture or brief fluid infusions. Leaving a rigid steel needle inside a vein for ongoing therapy is an unsafe nursing practice. It carries an extreme risk of puncturing the vessel wall during movement, leading to immediate vesicant drug infiltration into surrounding tissues.

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Question 8:

A client with a newly inserted peripherally inserted central catheter (PICC) reports sudden chest discomfort and shortness of breath shortly after insertion. Which nursing action is the priority?

A. Stop using the catheter and notify the healthcare provider immediately. B. Flush the catheter to verify patency. C. Encourage the client to cough and deep breathe. D. Place the client in high Fowler's position and reassess in 30 minutes.

Answer and Explanation

Choice A:

Stopping use of the catheter and notifying the healthcare provider immediately is the priority nursing action. The sudden onset of thoracic symptoms directly following a central line insertion signals a potential life-threatening injury that requires urgent diagnostic profiling via a chest radiograph. The line must not be utilized for any fluid or medication delivery until correct anatomical tip placement is confirmed and structural injury is ruled out. This rapid escalation ensures that emergency medical interventions, such as chest tube placement, can be initiated if necessary.

Choice B:

Flushing the catheter to verify patency is an unsafe action that is strictly contraindicated. If the catheter has perforated the vessel wall or migrated into the pleural cavity, introducing fluid will cause mediastinal or pleural fluid accumulation, worsening respiratory distress. Furthermore, if the symptoms are driven by an active air embolism, flushing can push remaining intraluminal air pockets directly into the right ventricle, accelerating a fatal pulmonary gas outflow obstruction.

Choice C:

Encouraging the client to cough and deep breathe is an inappropriate action that does not address the underlying mechanical injury. While deep breathing exercises are useful for managing routine atelectasis, they cannot resolve a collapsed lung or a central venous air lock. Relying on simple nursing comfort interventions during an acute procedural emergency causes dangerous delays in securing life-saving medical care.

Choice D:

Placing the client in a high Fowler's position and waiting 30 minutes to reassess is dangerous and delays critical care. If the symptoms are caused by an air embolism, a high Fowler's position can allow air bubbles to travel upward into the cerebral circulation, causing an ischemic embolic stroke. Additionally, deferring care for 30 minutes while a pneumothorax expands can lead to a tension pneumothorax, resulting in obstructive circulatory shock.

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Question 9:

The nurse is caring for a client with a central venous catheter. Which nursing interventions help reduce the risk of central line-associated bloodstream infection (CLABSI)? Select all that apply

A. Perform hand hygiene before handling the catheter. B. Disinfect the catheter hub before each access. C. Change dressings using a clean technique. D. Replace dressings only when drainage becomes excessive. E. Maintain a closed catheter system whenever possible.

Answer and Explanation

Choice A:

Performing thorough hand hygiene before handling the catheter or any part of the IV tubing setup is the foundational step in infection control. Proper hand wash or alcohol-based rub removes transient skin flora from the nurse's hands, preventing the mechanical transfer of pathogens to the central venous device.

Choice B:

Disinfecting the catheter hub before each access is an essential requirement. The nurse must scrub the injection port vigorously using an appropriate antiseptic (such as chlorhexidine gluconate or 70% alcohol) for at least 10 to 15 seconds. This mechanical friction destroys surface bio-films, preventing bacteria from being injected directly into the central venous pathway.

Choice C:

Changing central line dressings using a clean technique is incorrect and an unsafe practice. Central venous dressings must always be manipulated using strict surgical aseptic technique (sterile gloves, sterile drapes, and a mask). The insertion site provides a direct path to the heart, so using a non-sterile technique introduces skin microorganisms into the deep subcutaneous tissues, increasing the risk of site contamination.

Choice D:

Replacing dressings only when drainage becomes excessive allows infectious complications to progress undetected. Standard evidence-based protocols require changing transparent central line dressings routinely every 7 days, or immediately if they become loose, damp, or soiled. Waiting for drainage to become "excessive" means leaving a warm, moist environment in place, which encourages rapid bacterial growth right over the insertion track.

Choice E:

Maintaining a closed catheter system whenever possible limits environmental exposure. Every time an infusion line is disconnected or opened, the internal lumen is exposed to airborne contaminants or direct touch. Keeping the connections secure and minimizing unnecessary line breaks preserves the sterile fluid barrier.

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Question 10:

The nurse attempts to flush an implanted port but is unable to obtain blood return or infuse saline despite appropriate repositioning of the client. Which nursing action is most appropriate?

A. Apply additional pressure while flushing the catheter. B. Discontinue attempts to use the port and notify the healthcare provider. C. Remove the implanted port immediately. D. Continue administering medications through the port using slow pressure.

Answer and Explanation

Choice A:

Applying additional pressure while flushing the catheter is a dangerous nursing action that is strictly contraindicated. Intravenous ports are designed to withstand specific, limited pressure thresholds. Forcing fluid against a solid blockage generates high manual pressure that can easily cause catheter rupture or fragmentation, sending a free-floating plastic embolic shard directly into the right side of the heart.

Choice B:

Discontinuing attempts to use the port and notifying the healthcare provider is the most appropriate action. The port must be labeled non-functional and left completely unused to protect the client's vascular system. The provider will typically order a diagnostic evaluation or prescribe an intraluminal fibrinolytic agent (such as alteplase) to dissolve the suspected clot safely. The line cannot be used for any diagnostic or therapeutic purpose until patency is completely restored and verified.

Choice C:

Removing the implanted port immediately is a complex surgical procedure that falls completely outside the professional scope of nursing practice. An implanted port is surgically stitched into a subcutaneous pocket and threaded directly into the central venous anatomy. The nurse holds the responsibility to identify and report the occlusion, while a surgeon or interventional radiologist must perform the operative port explantation.

Choice D:

Continuing to administer medications through the port using slow pressure is unsafe and negligent. Attempting an infusion through an obstructed line can lead to severe subcutaneous drug extravasation. If the chemotherapy or hypertonic fluid leaks into the local tissue beds, it will cause intensive chemical inflammation, severe pain, and potentially widespread tissue necrosis.

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