A nurse is preparing a 45-year-old client with a family history of glaucoma for fluorescein angiography. The client has no known kidney issues and takes no regular medications. Which nursing intervention is most important to implement before the procedure?
A 65-year-old client with diabetic retinopathy is scheduled for fluorescein angiography to evaluate retinal blood vessel changes. The client has a history of mild kidney disease and takes metformin for diabetes management.
1Instruct the client to remove all jewelry and metal objects
2Ensure the client has been NPO for 8 hours prior to the procedure
3Administer prescribed mydriatic eye drops 30 minutes before the procedure
4Assess for allergies to iodine, shellfish, and contrast dyes✓ 정답
해설
Assessing for allergies to contrast dyes is critical before fluorescein angiography due to risk of severe allergic reactions like anaphylaxis. Other interventions are important but less urgent for preventing life-threatening complications.
Core Nursing Explanation
This question tests the priority nursing action before administering a diagnostic contrast agent, specifically for Fluorescein Angiography. The core concept is Patient Safety and Prevention of Adverse Reactions.
Key Concept Analysis
Fluorescein angiography is a diagnostic procedure where a fluorescent dye (sodium fluorescein) is injected intravenously (IV) to visualize blood flow in the retina. The dye is a Key Point!contrast medium. While generally safe, it carries a risk of allergic reactions ranging from mild (nausea, urticaria) to severe, life-threatening Anaphylaxis. The most critical nursing responsibility before administering any substance with allergic potential is a thorough allergy assessment.
Answer RationaleKey Point! Option ④ is correct because assessing for allergies to iodine, shellfish, and contrast dyes is the single most important intervention to prevent a severe, potentially fatal allergic reaction. This is a universal safety precaution for any procedure involving contrast media. The question provides two different client scenarios to emphasize that regardless of age or other health conditions (like kidney disease, which is more relevant to dye excretion), the allergy check is paramount.
Distractor Analysis
Option ① (Remove jewelry/metal objects): This is a standard pre-procedure safety measure for some imaging tests (like MRI) but is not specific to or critically urgent for fluorescein angiography. It does not address the highest risk of the procedure.
Option ② (Ensure NPO for 8 hours): Fluorescein angiography does not typically require the patient to be NPO (Nothing by Mouth). This is more common for procedures involving sedation, general anesthesia, or those with a high risk of aspiration. This instruction would be incorrect and unnecessary for this client.
Option ③ (Administer mydriatic drops): While dilating the pupil with mydriatic drops (e.g., tropicamide) is essential for obtaining clear retinal images during the angiography, it is a procedural step, not the highest-priority safety intervention. Administering medication comes after ensuring the client can safely receive the procedure's main component—the dye.
Related Concepts
The principle of "First, do no harm" is central here. Nursing prioritization (using frameworks like ABCs—Airway, Breathing, Circulation, or Maslow's Hierarchy of Needs) always places preventing life-threatening complications (like anaphylaxis) above procedural preparation steps. The history of kidney disease in the second scenario is a secondary concern; the dye is excreted renally, so kidney function should be assessed, but an allergic reaction is an immediate threat.Nursing Clinical Practice GuideClinical Scenario
You are a nurse in an ophthalmology clinic. Mr. Johnson, a 65-year-old with diabetic retinopathy, is scheduled for a fluorescein angiogram. During your pre-procedure assessment, he mentions he's "never had a problem with tests before" but recalls getting "a little itchy and wheezy" after eating shrimp years ago.
Nursing Intervention Strategy
1. Assessment: Before the procedure, conduct a focused interview. Ask specifically: "Have you ever had an allergic reaction to any medication, iodine, shellfish, or contrast dye used in X-rays or CT scans?" Document the response in detail.
2. Planning & Communication: If any allergy is suspected or confirmed, this is a STOP moment. Notify the ophthalmologist or radiologist immediately. The procedure may be canceled, or pre-medication (e.g., corticosteroids, antihistamines) may be ordered.
3. Implementation & Safety: Even with a negative allergy history, ensure emergency equipment is readily available in the procedure room: Epinephrine, antihistamines, corticosteroids, oxygen, and suction. Stay with the client during and immediately after the dye injection to monitor for reactions.
4. Patient Education: Inform the client that the dye will temporarily turn their skin slightly yellow and their urine a bright fluorescent yellow-orange for 24-48 hours. This is normal. Advise them to drink plenty of fluids to help excrete the dye, especially important for the client with mild kidney disease.
Patient Safety and Precautions
Contraindication: A known severe allergy to fluorescein dye is an absolute contraindication.
Medication Alert: For diabetic patients on Metformin, there is a caution regarding contrast dye and the risk of Lactic Acidosis. While more associated with iodinated contrast for CT scans, protocols often involve holding metformin before and after procedures involving IV contrast. This requires a specific physician order.
Monitoring: Closely monitor for signs of reaction during injection: urticaria (hives), pruritus (itching), dyspnea (shortness of breath), wheezing, hypotension, or feeling of throat tightness.
Consent: Ensure informed consent is obtained and the procedure is explained.
Health History: Note history of kidney disease, asthma, or other allergies.
Medication Review: Check for metformin use; follow facility protocol for holding.
Procedure Prep: Administer mydriatic eye drops as ordered to dilate pupils.
IV Access: Establish a patent IV line for dye injection.
Emergency Readiness: Confirm crash cart/emergency kit is accessible.
A Word from Your Senior Nurse
"In the fast-paced clinical world, it's easy to get caught up in the routine steps of a procedure. But never let routine override critical thinking. That one question—'Are you allergic to anything?'—asked thoughtfully and documented clearly, is a nurse's primary shield against catastrophe. For fluorescein angiography, the dye is the hazard. Your first job is to identify if your patient is at risk from that hazard. This mindset of 'safety first' is what the NCLEX tests and, more importantly, what defines excellent nursing care."
Concept Summary
Fluorescein Angiography: Diagnostic eye test using IV fluorescent dye to visualize retinal circulation.
Priority Intervention: Assess for allergies to contrast dye, iodine, shellfish before administration.
Major Risk: Anaphylactic reaction to the dye.
Nursing Role: Prevention through screening, preparation, monitoring, and emergency readiness.
Side-by-Side Comparison!
Pre-Procedure Focus
Fluorescein Angiography
CT Scan with Iodinated Contrast
Critical Nursing Action
Assess for dye allergy
Assess for iodine/shellfish/dye allergy
NPO Required?
Typically No
Often Yes (to prevent aspiration if nausea/vomiting occurs)
Key Organ Monitoring
Allergy response (systemic)
Allergy response & Kidney function (contrast-induced nephropathy)
Common Patient Instruction
Urine will be discolored (yellow-orange)
Drink plenty of fluids after to protect kidneys
Anatomy, Physiology & Pharmacology Points
Dye Pathway: Sodium fluorescein is injected IV → circulates → highlights retinal Blood vessels → filtered by the Kidneys and excreted in urine.
Why Allergy? The dye acts as a foreign substance (antigen) that can trigger an IgE-mediated hypersensitivity (allergic) reaction in susceptible individuals.
Mydriatic Drops: Drugs like tropicamide paralyze the iris sphincter muscle and dilate the pupil (Mydriasis), allowing a better view of the retina.
Memory Tips
Acronym: S.A.F.E. Dye Screen for Allergies first.
Assess IV access.
Fluids encouraged after.
Emergency equipment ready.
Dye will discolor urine.
Think: "Contrast = Caution". Any time you see "contrast," "dye," or "angiography," your first mental check is ALLERGY.
High-Frequency NCLEX Topics
This question integrates several high-yield NCLEX concepts:
1. Prioritization (Safety First): Always choose the action that prevents harm over routine preparation.
2. Allergic Reaction/Anaphylaxis: Recognition and prevention are critical.
3. Diagnostic Procedures: Understanding the nurse's role before, during, and after tests.
4. Patient Education: Teaching about expected side effects (urine discoloration).
Watch Out for Question Variations!
Shift from "Assess" to "Intervene": "The client develops hives and dyspnea 2 minutes after fluorescein injection. What is the nurse's priority action?" (Answer: Administer epinephrine per protocol/stop the procedure/call for help).
Focus on Comorbidity: "A client with chronic kidney disease (CKD) is scheduled for fluorescein angiography. Which action is most important?" (While allergy is still top, a strong distractor would be "Monitor serum creatinine before and after" – kidney protection is important but secondary to preventing an acute allergic crisis).
Patient Teaching Focus: "Which statement by a client after fluorescein angiography indicates understanding of the teaching?" (Correct: "My urine will be bright yellow for a day or two." Incorrect: "I need to stay NPO for 4 hours after the test.").
Fluorescein Angiography — A diagnostic ophthalmic procedure where sodium fluorescein dye is injected intravenously to photograph the circulation of blood in the retina and choroid. Used to diagnose conditions like diabetic retinopathy, macular degeneration, and retinal vessel occlusions.
Anaphylaxis — A severe, life-threatening systemic allergic reaction characterized by rapid onset of symptoms such as airway obstruction (stridor, wheezing), hypotension, and generalized urticaria or angioedema. It is a medical emergency requiring immediate administration of epinephrine.
Mydriatic — A type of eye drop (e.g., tropicamide, phenylephrine) that causes dilation of the pupil (mydriasis) by paralyzing the iris sphincter muscle or stimulating the dilator muscle. Used in eye exams and procedures to provide a better view of the internal structures of the eye.
Contrast Medium — A substance used in medical imaging to improve the visibility of internal body structures. It can be administered orally, rectally, or intravenously. Allergic reactions are a primary concern with IV administration.
Metformin — A first-line oral antihyperglycemic medication for Type 2 Diabetes Mellitus. It works by decreasing hepatic glucose production and increasing insulin sensitivity. A key precaution is the risk of lactic acidosis, which may be increased in the setting of acute kidney injury from procedures using IV contrast.