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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A weight gain of 1 lb in a week may not indicate fluid overload, but a more rapid increase is concerning.
B. A weight gain of 2 lbs in 24 hours or 5 lbs in a week suggests worsening heart failure due to fluid retention, requiring immediate provider notification.
C. Daily weights should be taken at the same time each day, preferably in the morning, after urination and before eating, for accurate monitoring.
D. Skipping a diuretic dose can lead to fluid retention and worsening symptoms, so adherence to the medication regimen is crucial.

A. Murmur B. S3 and S4 C. Friction rub D. Click

Correct Answer is A

Explanation

A. A murmur is the expected heart sound in mitral valve regurgitation, caused by the backflow of blood into the left atrium during systole. It is typically a holosystolic murmur heard best at the apex of the heart.
B. S3 and S4 heart sounds may be heard in heart failure but are not specific for mitral regurgitation.
C. A friction rub is associated with pericarditis, not valvular disease.
D. A click is typically heard in mitral valve prolapse, not mitral regurgitation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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