The nurse is caring for a patient who underwent a cardiac catheterization. The sheaths have just been removed. You should assess the patient carefully for what potential complication?
a. Vasovagal reaction
b. Hypertension
c. Tachycardia
d. Allergic reaction
A
Before removing the catheter sheath, check the health care provider's orders for instructions on treating a vasovagal reaction. Manual pressure applied to the groin/femoral area can stimulate the baroreceptors and cause a vasovagal reaction in which the patient becomes bradycardic and hypotensive. Vasovagal reactions are usually brief and self-limited. When applying pressure to the groin after sheath removal, be alert for a vasovagal reaction and be prepared to treat it by lowering the head of the bed to the flat position and giving a bolus of IV fluids.
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The nurse is caring for a client with uncontrolled hypertension. His blood pressure has remained controlled for the nurse's shift. At 2-hour intervals the blood pressure was checked by the nurse and found to be essentially the same
The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the client has a stroke. Years later, the client files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the client when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why? A) Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition. B) No, but it will relieve the nurse of any wrongdoing. C) No, if the blood pressure measurement was not documented, it did not happen. D) Yes, the nurse was not on duty when the stroke occurred.