A newly licensed nurse is assessing a client who had a cardiac catheterization with a right femoral insertion site. Which of the following pulses should the nurse palpate?

Brachial pulse in the right upper extremity

Pedal pulses in the right lower extremity

Popliteal pulse in the left lower extremity

Radial pulse in the right upper extremity

Answer and Explanation

The Correct Answer is B

Choice A reason: Palpating the brachial pulse in the right upper extremity is irrelevant for a right femoral catheterization. The brachial pulse assesses arm circulation, not the lower extremity, where the procedure occurred. Monitoring distal pulses in the affected leg is critical to detect vascular complications like arterial occlusion.

Choice B reason: Pedal pulses (dorsalis pedis and posterior tibial) in the right lower extremity must be palpated post-right femoral catheterization. These distal pulses indicate adequate blood flow to the limb, detecting complications like thrombosis or arterial occlusion at the puncture site, ensuring no compromise to leg perfusion.

Choice C reason: Palpating the popliteal pulse in the left lower extremity is incorrect, as the catheterization was performed on the right side. Assessing the unaffected leg does not provide information about potential vascular complications, such as occlusion or bleeding, specific to the right femoral insertion site.

Choice D reason: The radial pulse in the right upper extremity assesses arm circulation, not relevant to a right femoral catheterization. Monitoring pulses in the affected leg (right pedal pulses) is essential to evaluate for vascular complications like reduced perfusion or thrombosis at the femoral site.

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Correct Answer is D

Explanation

Choice A reason: An edematous bruise on the forehead is expected after a head injury and, while concerning, is not the most urgent finding. It indicates localized trauma but does not necessarily suggest intracranial complications like cerebrospinal fluid leakage, which poses a greater risk of infection or brain injury.

Choice B reason: A Glasgow Coma Scale score of 14 indicates mild impairment (normal is 15), which is concerning but not the priority. Clear ear drainage suggesting cerebrospinal fluid leak is more urgent, as it indicates a potential skull fracture and risk of meningitis, requiring immediate reporting.

Choice C reason: Pupils that are 4 mm and reactive to light are normal and not immediately concerning. This finding suggests intact cranial nerve function. Clear ear drainage, potentially cerebrospinal fluid, is a more critical sign of skull fracture or brain injury, warranting urgent provider notification.

Choice D reason: Small drops of clear drainage in the ear are highly concerning, as they may indicate cerebrospinal fluid leakage from a basilar skull fracture post-head injury. This poses a risk of meningitis or brain infection, requiring immediate reporting to the provider for diagnostic imaging and intervention.

A. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion B. These tests will enable the provider to determine the heart structure and mobility of the heart valves C. These tests help determine the degree of damage to the heart tissues D. Cardiac enzymes will identify the location of the MI

Correct Answer is C

Explanation

Choice A reason: Cardiac enzymes, such as troponin, do not diagnose pulmonary congestion, which is assessed via imaging or clinical signs like crackles. These enzymes (troponin, CK-MB) are released from damaged myocardial cells during an MI, indicating heart tissue injury rather than lung-related conditions like congestion.

Choice B reason: Cardiac enzymes do not assess heart structure or valve mobility, which are evaluated using imaging techniques like echocardiography. Enzymes like troponin and CK-MB are specific to myocardial damage, rising in the blood post-MI to indicate the extent of heart tissue injury, not structural details.

Choice C reason: Cardiac enzyme tests, particularly troponin and CK-MB, measure the degree of myocardial damage after an MI. These proteins are released into the bloodstream when heart muscle cells die, with elevated levels correlating to the extent of tissue injury, aiding in assessing MI severity.

Choice D reason: Cardiac enzymes do not pinpoint the exact location of an MI. Localization is achieved through EKG changes or imaging like cardiac catheterization. Enzymes indicate the presence and extent of myocardial damage but lack specificity for identifying which coronary artery or heart region is affected.

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A newly licensed nurse is assessing a client who had a cardiac catheterization with a right femoral insertion site. Which of the following pulses should the nurse palpate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is teaching a family member of a client who had an acute myocardial infarction (MI) about the reason for the frequent blood draws from the client. Which of the following statements is appropriate for the nurse to say when educating the family member about cardiac enzymes?

Correct Answer is C

Explanation

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