A nurse is caring for a client following a cardiac catheterization that was inserted through the femoral artery. While turning the client, the nurse discovers ecchymosis underneath the clients lower back. Which priority action would the nurse initiate?
Obtain a STAT electrocardiogram.
Remove the closure device and assess the incision.
Reposition the client to semi-fowlers.
Apply manual pressure over the closure device.
The Correct Answer is D
A. Obtain a STAT electrocardiogram: While monitoring cardiac status is important, ecchymosis under the lower back following femoral artery catheterization indicates possible bleeding at the insertion site. Immediate hemostatic intervention takes priority over EKG monitoring.
B. Remove the closure device and assess the incision: The closure device should not be removed by the nurse, as this could worsen bleeding or disrupt vascular repair. Only trained personnel following strict protocol can manage or remove the device.
C. Reposition the client to semi-fowlers: Semi-fowler positioning may improve comfort or respiratory function, but it does not address the active concern of potential bleeding from the femoral artery site. Immediate pressure is needed to prevent hemorrhage.
D. Apply manual pressure over the closure device: Ecchymosis on the lower back may indicate retroperitoneal bleeding from the femoral artery. Applying firm, manual pressure over the insertion site is the priority intervention to control bleeding, prevent further blood loss, and stabilize the client while notifying the provider for urgent assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Ordered Dose: 0.5 mg/min
Available Concentration: 1 g/500 mL (1000 mg/500 mL)
Convert concentration to mg/mL
Concentration = 1000 ÷ 500
= 2 mg/mL
Convert the ordered dose to mg/hr
Dose per hour = 0.5 mg × 60 min
= 30 mg/hr
Calculate the flow rate in mL/hr
Flow Rate = Dose per hour ÷ Concentration
= 30 ÷ 2
= 15 mL/hr
Correct Answer is D
Explanation
A. EKG showing sinus tachycardia, rate 112: After a heart transplant, the heart is denervated, and mild resting tachycardia (90–110 bpm) is common. A rate of 112 can occur and, by itself, does not specifically indicate rejection.
B. Blood pressure 154/90: Mild hypertension is common in transplant recipients due to immunosuppressive therapy (such as corticosteroids or calcineurin inhibitors). This finding alone does not strongly suggest rejection.
C. White blood cell count 11,000: A WBC count of 11,000 is only slightly elevated and may reflect stress or mild infection. It is not a specific indicator of transplant rejection.
D. Ejection fraction of 20%: A significantly decreased ejection fraction indicates poor ventricular function. In a client 6 months post–heart transplant, a marked drop in ejection fraction strongly suggests acute or chronic rejection and requires immediate evaluation and intervention.
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