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 D
Explanation
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.
Correct Answer is A
Explanation
A. Atrial fibrillation is characterized by an irregularly irregular rhythm with no distinct P waves on the ECG. Instead, there are fibrillatory waves due to chaotic atrial activity, and the ventricular rate may be rapid or controlled.
B. Junctional rhythm originates from the AV node and is typically characterized by absent or inverted P waves, a narrow QRS complex, and a regular rhythm.
C. First-degree heart block presents with a prolonged PR interval (>0.20 seconds) but has a regular rhythm and identifiable P waves preceding each QRS complex.
D. Sinus tachycardia is a regular rhythm with a heart rate greater than 100 beats per minute, with distinct P waves before each QRS complex.
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