A nurse is caring for a client post-cardiac catheterization with a right radial artery puncture site. The nurse performs which priority assessment on arrival to the unit?
Place a pressure dressing over the site.
Have the client flex and extend the right wrist.
Place the patient on oxygen.
Assess the trans-radial (TR) band.
The Correct Answer is D
A. A pressure dressing is already in place following the procedure, and additional dressing is not the priority. Instead, monitoring the TR band for bleeding or complications is essential.
B. Having the client flex and extend the right wrist is not recommended immediately after a radial artery catheterization, as movement can increase the risk of bleeding.
C. Oxygen therapy is not routinely required unless the client has hypoxia or respiratory distress.
D. Assessing the trans-radial (TR) band is the priority to ensure proper hemostasis at the puncture site, monitor for bleeding, and check distal circulation to the hand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.
Correct Answer is ["C","D","E"]
Explanation
A. Assessing for acute pain is unnecessary. Sinus bradycardia is not typically associated with acute pain unless another condition, such as myocardial infarction, is present.
B. Monitoring fluid volume excess is incorrect. Sinus bradycardia is not directly related to fluid overload; however, fluid status may need to be monitored in clients with underlying cardiac conditions.
C. Prevention of falls is correct. Bradycardia can lead to dizziness, hypotension, and syncope, increasing the risk of falls.
D. Monitoring heart rate and rhythm is correct. Continuous monitoring is essential to detect any worsening bradycardia or associated arrhythmias.
E. Assessing for neurologic changes is correct. Bradycardia can reduce cerebral perfusion, leading to symptoms such as confusion, dizziness, or syncope.
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