A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

Assess the insertion site.

Keep the client NPO for 4 hr.

Keep the affected leg slightly flexed.

Elevate the head of the bed 45°.

Answer and Explanation

The Correct Answer is A

A. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.

B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.

C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.

D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.

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Correct Answer is A

Explanation

A. Tachypnea: Tachypnea, or rapid breathing, is a common symptom of pulmonary embolism. It occurs as the body attempts to compensate for decreased oxygenation and increased carbon dioxide levels resulting from impaired blood flow to the lungs. Tachypnea helps to improve gas exchange by increasing ventilation.

B. Wet cough: A wet or productive cough may occur in conditions such as pneumonia or chronic bronchitis but is not typically associated with pulmonary embolism. Pulmonary embolism is more commonly characterized by symptoms such as dyspnea, chest pain, and tachypnea.

C. Dull chest pain: Chest pain associated with pulmonary embolism is often sharp and pleuritic, meaning it worsens with deep breathing or coughing. It may be described as stabbing or like a "knife-like" sensation. Dull chest pain is not a typical finding in pulmonary embolism.

D. Episodes of apnea: While severe cases of pulmonary embolism can lead to respiratory failure and apnea, it is not a common presenting symptom. Most clients with pulmonary embolism will exhibit tachypnea as a compensatory mechanism to maintain adequate oxygenation.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Pneumocystis pneumonia (PCP) is a common opportunistic infection in individuals with AIDS, particularly when their CD4 T-cell count falls below 200/mm3. PCP is caused by the fungus Pneumocystis jirovecii and is a significant cause of morbidity and mortality in AIDS patients. The CD4 T-cell count is a key indicator of immune function in HIV/AIDS patients. A CD4 T-cell count below 200/mm3 is indicative of severe immune suppression and significantly increases the risk of opportunistic infections such as pneumocystis pneumonia.

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A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

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