A client returns to the unit following a cerebral angiogram via the femoral artery that was performed two hours ago. In assessing this client, which finding requires immediate intervention by the nurse?
Blood pressure measurement of 122/84 mm Hg and a heart rate of 88 beats/minute.
No urinary output measured since the procedure.
Diminished volume of right dorsalis pedis pulse.
Client reports feeling hot during the procedure and cold afterward.
The Correct Answer is C
Rationale:
A. Blood pressure measurement of 122/84 mm Hg and a heart rate of 88 beats/minute: These vital signs are within acceptable limits and do not indicate an acute complication following a cerebral angiogram. No immediate intervention is required for these values.
B. No urinary output measured since the procedure: While monitoring urine output is important, a two-hour gap post-procedure may not yet indicate a critical problem. The nurse should continue to monitor and assess, but this is not the most urgent finding.
C. Diminished volume of right dorsalis pedis pulse: A weak or absent peripheral pulse following femoral artery catheterization may indicate arterial obstruction, thrombus, or compromised distal perfusion. Immediate intervention is required to restore circulation and prevent tissue ischemia.
D. Client reports feeling hot during the procedure and cold afterward: These sensations may reflect normal physiological responses to contrast media or procedural stress. While worth noting, they do not require urgent intervention compared to compromised limb perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Rationale:
• Auscultation of bruit: A bruit represents turbulent blood flow through a weakened arterial wall, commonly heard over an abdominal aortic aneurysm (AAA). This finding is due to the high-velocity flow through the dilated section of the aorta, which creates a buzzing or whooshing sound on auscultation.
• Pulsatile mass: A palpable or visible pulsating abdominal mass is a hallmark feature of an AAA. It reflects the dilation of the aorta, often located near the periumbilical region, and can sometimes be accompanied by tenderness as the aneurysm expands.
• Back pain: The aneurysm may compress nearby structures or leak slightly, causing referred pain to the lower back or flank area. This pain is often steady, deep, and unrelieved by position changes or common analgesics like acetaminophen.
• Feeling of fullness: Tumors in the stomach can obstruct normal gastric emptying, leading to early satiety and abdominal fullness even after small meals. This occurs as the growing mass occupies space and interferes with digestion and gastric motility.
• Fatigue: Chronic blood loss from the tumor or poor nutritional intake can cause anemia, leading to generalized fatigue and weakness. This symptom tends to develop gradually as the disease progresses and nutritional absorption declines.
Correct Answer is A
Explanation
Rationale:
A. Heart rate of 40 beats/minute: A sudden drop in heart rate following initial tachycardia in a trauma client with hypotension may indicate neurogenic shock or worsening spinal cord injury. This bradycardia reflects loss of sympathetic tone and signifies cardiovascular collapse, making it a critical, life-threatening deterioration.
B. Glasgow coma score of 15: A GCS of 15 represents full neurological alertness and orientation. This finding indicates improvement or stability, not deterioration, in a trauma client’s neurological status.
C. Oxygen saturation 90 percent: While this indicates mild hypoxemia requiring intervention, it is not as severe or immediately life-threatening as the transition from tachycardia to bradycardia in the setting of shock. Oxygen supplementation can typically correct this decline.
D. Respiration 34 breaths/minute: An increase in respiratory rate signals distress or pain but still maintains ventilatory effort. Though concerning, it does not reflect a critical deterioration compared to severe bradycardia with hypotension, which threatens perfusion and cardiac output.
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