A client is two hours postoperative from a cardiac catheterization via the right femoral artery.
Which assessment finding indicates arterial obstruction?
The right foot is cool to the touch and appears pale and blanched.
The pressure dressing at the right femoral area is moist and oozing blood.
The client’s blood pressure trend is downward, and the pulse is rapid and irregular.
The pulse distal to the femoral artery is weaker on the left foot than the right foot.
The Correct Answer is A
Choice A rationale
The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.
Choice B rationale
While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.
Choice C rationale
A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.
Choice D rationale
A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.
Choice B rationale
Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.
Choice C rationale
Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.
Choice D rationale
An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.
Choice E rationale
Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.
Choice F rationale
An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.
Correct Answer is B
Explanation
Choice A rationale
Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.
Choice B rationale
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.
Choice C rationale
Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.
Choice D rationale
Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
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