A client is recovering in the critical care unit following a cardiac catheterization.
Intravenous (IV) nitroglycerin and heparin are infusing.
The client is sedated but responds to verbal instructions.
After changing positions, the client complains of pain at the right groin insertion site.
Which action should the nurse implement?
Check femoral site for hematoma formation.
Stimulate the client to take deep breaths.
Evaluate the integrity of the IV insertion site.
Assess distal lower extremity capillary refill.
The Correct Answer is A
Choice A rationale:
Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.
Choice B rationale:
Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.
Choice C rationale:
Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.
Choice D rationale:
Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
According to the Mormon dietary code, also known as the Word of Wisdom, Mormons are prohibited from consuming alcohol, tobacco, coffee, and tea.They are also advised to eat meat sparingly and consume fruits, vegetables, and whole grains. Therefore, the nurse should request the following menu items for this client:
- Orange juiceandapple juice, as they are clear liquids and fruits that are allowed by the Word of Wisdom.
- Chicken broth, as it is a clear liquid and a source of protein that can be consumed in moderation.
- Not hot chocolate, as it contains caffeine, which is a stimulant and a "hot drink" that is forbidden by the Word of Wisdom.
Correct Answer is D
Explanation
Choice A rationale:
Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.
Choice B rationale:
Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.
Choice C rationale:
Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.
Choice D rationale:
Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.
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