The nurse is providing post procedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with
... [Show More] embolization. Which action should the nurse take?
Notify the primary healthcare provider immediately
Apply a warm, moist compress to the incision site
Increase the intravenous fluid rate by 20 mL/hr
Monitor vital signs more frequently - Notify the primary healthcare provider immediately
The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.
The nurse assesses a client for orthostatic hypotension. The results are:
Lying heart rate = 70 beats/minute, BP = 110/70;
Sitting heart rate = 78 beats/minute, BP = 106/66;
Standing heart rate = 85 beats/minute, BP = 100/64.
The nurse would expect which prescription from the primary healthcare provider?
Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily
Give 1 L of 0.9% normal saline (NS) bolus over 4 hours
Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr
No prescription change - No prescription change
The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best?
"The cause is abnormal configurations of the veins."
"The cause is incompetent valves of superficial veins."
"The cause is decreased pressure within the deep veins."
"The cause is atherosclerotic plaque formation in the veins." - The cause is incompetent valves of superficial veins.
Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?
Loosen the dressing slightly.
Notify the primary healthcare provider.
Assess the pulses distal to the dressing.
Have the client flex the joints of the right leg. - Assess the pulses distal to the dressing
Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary healthcare provider is premature; the primary healthcare provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours. [Show Less]