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    Med Surg 2 Proctored ExamQuestion 60
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    Med Surg 2 Proctored Exam

    The nurse is caring for a client after a heart catheterization. What cooperation must the nurse intervene for immediately?

    Explanation & Rationale

    A. 2+ bilateral peripheral edema: Mild peripheral edema is a common finding in clients with cardiac history or post-procedure fluid shifts. While it should be monitored, it does not indicate an acute, life-threatening complication after heart catheterization. B. Temperature of 96 F: Mild hypothermia may occur due to exposure in the procedure area or anesthesia. Although it warrants monitoring, it is not an immediate life-threatening condition and does not require emergent intervention. C. Muffled heart sounds: Muffled or distant heart sounds can indicate pericardial effusion or cardiac tamponade, a critical complication after heart catheterization. Tamponade can rapidly lead to hemodynamic collapse, hypotension, and shock. Immediate intervention is required, including notifying the provider and preparing for emergency measures. D. Heart rate 59 beats/min: A mild bradycardia may be expected in some clients post-procedure, particularly if sedatives or beta-blockers were used. While it should be monitored, it is not immediately life-threatening unless accompanied by hypotension or other symptoms.

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