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 D

Explanation

A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.

B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.

C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.

D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.

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

Explanation

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