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: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

A. Disagreements among health care team members. B. Failure to discuss end-of-life issues with patient. C. Aggressive pain management. D. Belief that treatment is harmful. E. Following the patient’s advance directive despite family objections. F. Providing hope to the patient’s family.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Disagreements among team members signal conflicting values, an early ethical dilemma indicator. This aligns with healthcare ethics, making it a correct situation, as it highlights potential ethical tensions that the nurse should recognize as requiring resolution in patient care.

Choice B reason: Failure to discuss end-of-life issues with the patient violates autonomy, creating an ethical dilemma. This aligns with ethical principles of patient involvement, making it a correct early sign the nurse should identify in healthcare decision-making processes.

Choice C reason: Aggressive pain management is a clinical decision, not inherently an ethical dilemma unless harm is suspected. Disagreements or belief in harm are clearer signs, making this incorrect, as it lacks the ethical conflict context in the nurse’s evaluation.

Choice D reason: Believing treatment is harmful raises ethical concerns about beneficence and nonmaleficence, indicating a dilemma. This aligns with ethical care standards, making it a correct situation the nurse should recognize as an early sign of an ethical issue in treatment decisions.

Choice E reason: Following an advance directive despite family objections creates an ethical conflict between patient autonomy and family wishes. This aligns with end-of-life ethics, making it a correct early sign of a dilemma the nurse should identify in patient care.

Choice F reason: Providing hope to the family is supportive and not inherently an ethical dilemma unless it involves deception. Failure to discuss end-of-life issues is a clearer sign, making this incorrect, as it lacks the ethical conflict context in the nurse’s assessment.

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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

Correct Answer is D

Explanation

Which situations are early signs of an ethical dilemma? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

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