A nurse is assessing a client immediately following a cardiac catheterization.
The nurse should notify the provider for which of the following findings?
Heart rate 90/min.
Hematoma over the insertion site.
Bounding pulses in the affected extremity.
Report of discomfort at the insertion site continue.
The Correct Answer is B
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because heart rate 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed, but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. A client who is taking warfarin and has an INR of 1.8.
Choice A rationale:
An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.
Choice B rationale:
Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.
Choice C rationale:
A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.
Choice D rationale:
An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.
Correct Answer is D
Explanation
The correct answer is choice D. Sit at or below the client’s eye level during feedings.
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
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