A client returns to the unit immediately following a cardiac catheterization. Which action by the nurse is MOST important?

Ask the client to rate the location and severity of pain at the insertion site.

Assess bilateral dorsalis pedis and posterior tibial pulses.

Observe the catheter access site.

Check bilateral lower extremity capillary refill time.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing pain at the insertion site is important but less urgent than ensuring vascular patency post-catheterization. Checking pulses detects complications like occlusion, making this incorrect, as it’s secondary to the nurse’s priority of monitoring for vascular issues immediately post-procedure.

Choice B reason: Assessing dorsalis pedis and posterior tibial pulses is most important to detect vascular complications, such as arterial occlusion, post-cardiac catheterization. This aligns with post-procedure protocols, making it the correct action to ensure limb perfusion and prevent serious complications immediately.

Choice C reason: Observing the access site for bleeding is key but secondary to ensuring distal perfusion via pulses. Vascular occlusion is a greater risk, making this incorrect, as it’s less urgent than the nurse’s priority of checking pulses post-cardiac catheterization.

Choice D reason: Checking capillary refill time assesses perfusion but is less specific than pulse assessment for detecting arterial issues post-catheterization. Pulses are the priority, making this incorrect, as it’s secondary to the nurse’s focus on immediate vascular integrity post-procedure.

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Correct Answer is D

Explanation

Choice A reason: Monitoring temperature detects infection but is less urgent than ensuring airway safety post-endoscopy. Gag reflex assessment prevents aspiration, making this incorrect, as it’s secondary to the nurse’s priority of confirming safe swallowing after the procedure.

Choice B reason: Heartburn monitoring is relevant for ulcers but not the immediate post-endoscopy priority. Gag reflex return is critical, making this incorrect, as it’s less urgent than the nurse’s focus on airway protection after esophagogastroduodenoscopy in the client.

Choice C reason: Warm gargles soothe a sore throat but don’t address the risk of aspiration post-endoscopy. Assessing gag reflex is vital, making this incorrect, as it’s not the highest priority compared to the nurse’s focus on ensuring airway safety.

Choice D reason: Assessing the return of the gag reflex post-esophagogastroduodenoscopy is the highest priority to prevent aspiration due to sedation. This aligns with post-procedure safety, making it the correct item for the nurse to prioritize in the client’s care plan.

A. Decreased cardiac output. B. Increased pulse rate. C. Postural hypotension. D. Bounding pulse. E. Weak thready pulse. F. Hypertension. G. Capillary refill greater than 3 seconds. H. Capillary refill less than 3 seconds. I. Pink frothy sputum.

Correct Answer is ["A","B","E","G","I"]

Explanation

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

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A client returns to the unit immediately following a cardiac catheterization. Which action by the nurse is MOST important?

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Explanation

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