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 ["C","D","F","G","H"]

Explanation

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

A. The nurse discusses the pulse oximetry findings with the client. B. The client has the pulse oximeter and automatic blood pressure cuff on the same arm. C. The pulse oximeter is placed on the ring finger of the client’s right hand. D. The nurse instructs nursing assistive personnel to obtain a pulse oximetry reading.

Correct Answer is B

Explanation

Choice A reason: Discussing pulse oximetry findings with the client is appropriate and promotes understanding, not requiring intervention. A blood pressure cuff on the same arm affects readings, making this incorrect, as it’s a correct nursing action for the client with Raynaud’s and diabetes.

Choice B reason: A blood pressure cuff on the same arm as the pulse oximeter disrupts blood flow, causing inaccurate readings, especially in Raynaud’s disease. This requires intervention, aligning with monitoring accuracy standards, making it the correct situation for the nurse to address immediately.

Choice C reason: Placing the pulse oximeter on the ring finger is appropriate, avoiding Raynaud’s-affected areas. A cuff on the same arm is problematic, making this incorrect, as it’s a standard placement not requiring intervention in the client’s monitoring setup.

Choice D reason: Instructing assistive personnel to obtain readings is acceptable if within their scope. A cuff on the same arm affects accuracy, making this incorrect, as it’s not an issue compared to the intervention needed for the pulse oximeter placement error.

Choice E reason: An LPN recording the pulse from the oximeter is within their role and not problematic. A cuff on the same arm requires intervention, making this incorrect, as it’s a correct action unlike the inaccurate monitoring setup needing nurse correction.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

Correct Answer is ["C","D","F","G","H"]

Explanation

The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

Correct Answer is B

Explanation

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

A nurse is admitting a client with pneumonia. Which of the following orders should be implemented first?

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)