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

Explanation

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Hypertensive crisis can cause severe headache, risk for stroke, pulmonary edema, and difficulty breathing. Elevating the HOB improves cerebral perfusion, reduces intracranial pressure, and eases breathing. This is an immediate, noninvasive, airway/circulation-supportive intervention.

Choice D reason: Needed for IV antihypertensive administration, but initial safety and circulation support (C) takes priority before establishing access.

A. Eating leafy green vegetables with a glass of water. B. Eating apple slices with carrots. C. Eating a steak with mushrooms. D. Eating calf’s liver with a glass of orange juice.

Correct Answer is D

Explanation

Choice A reason: Leafy greens contain iron, but water doesn’t enhance absorption; vitamin C does. Calf’s liver with orange juice maximizes absorption, making this incorrect, as it lacks the vitamin C component the nurse should teach to improve iron uptake in anemia.

Choice B reason: Apples and carrots have minimal iron and no vitamin C to enhance absorption. Calf’s liver with orange juice is optimal, making this incorrect, as it doesn’t provide iron or absorption enhancers compared to the nurse’s teaching for iron deficiency anemia.

Choice C reason: Steak is iron-rich, but mushrooms don’t significantly enhance absorption like vitamin C. Orange juice with liver is better, making this incorrect, as it’s less effective than the nurse’s recommendation to pair iron with a vitamin C source for anemia.

Choice D reason: Calf’s liver is high in iron, and orange juice’s vitamin C enhances non-heme iron absorption. This aligns with nutritional education for iron deficiency anemia, making it the correct choice for the nurse to teach the client to improve iron absorption effectively.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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