When caring for a client after cardiac catheterization which nursing action is most important

3. Dependent edema
Rationale:
Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

3. The pain has not been unrelieved by rest and nitroglycerin tablets.
Rationale:
The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.

4. Ingestion of coffee or chocolate
Rationale:
Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

3. The client complains of leg edema, and skin breakdown has started.
Rationale:
Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

3. Precipitate rebound hypertension
Rationale:
Beta-adrenergic blocking agents should be tapered slowly. This will avoid abrupt withdrawal syndrome, characterized by headache, malaise, palpitations, tremors, sweating, rebound hypertension, dysrhythmias, and possibly myocardial infarction (in clients with cardiac disorders, including angina pectoris). Options 1, 2, and 4 are incorrect.

The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu?

1. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet
2. Pork chop, baked potato, cauliflower in cheese sauce, ice cream
3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries
4. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries
Rationale:
A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 3 is the only option that identifies low-fat and low-cholesterol foods.

What is most important to do for a patient after cardiac catheterization?

What does a nurse do after a cardiac catheterization?

Which nursing interventions are priorities in care following cardiac catheterization?

What should you assess after cardiac catheterization?