A nurse is caring for a client who had a femoral artery cannulation for an invasive procedure. What is the priority nursing assessment?
Pain level at the insertion site
Peripheral pulses distal to the insertion site
Client's ability to ambulate independently
Capillary refill of the fingers
The Correct Answer is B
A) Incorrect - Assessing pain level at the insertion site is important but not the priority assessment when evaluating the immediate complications of femoral artery cannulation.
B) Correct - Assessing peripheral pulses distal to the insertion site is the priority when evaluating the adequacy of blood flow after femoral artery cannulation. Diminished or absent pulses may indicate vascular compromise.
C) Incorrect - The client's ability to ambulate independently is a relevant assessment but not the priority when immediately assessing the complications of femoral artery cannulation.
D) Incorrect - Capillary refill of the fingers is important but is not the priority assessment in the immediate post-procedure period following femoral artery cannulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Pain level assessment is essential in monitoring for aneurysm rupture because sudden, severe, and persistent pain is a common manifestation. It could indicate that the aneurysm is leaking or has ruptured, requiring immediate medical attention.
B) Incorrect - While blood pressure measurement is important in managing aneurysm, it may not be the best indicator of an imminent rupture. Some aneurysms are asymptomatic until they rupture.
C) Incorrect - Respiratory rate evaluation is not a primary assessment for aneurysm rupture. Although respiratory distress may occur due to pain or compromised blood flow after rupture, it is not the initial priority.
D) Incorrect - While monitoring urinary output is important in various clinical settings, it is not a priority assessment for aneurysm rupture. There are more specific symptoms related to aneurysm rupture that the nurse should focus on.
Correct Answer is B
Explanation
A) Incorrect - Limiting daily water intake is not a lifestyle modification that directly impacts aneurysm prevention. Adequate hydration is generally encouraged for overall health.
B) Correct - Engaging in regular aerobic exercise is a lifestyle modification that can help prevent aneurysms and promote cardiovascular health. Exercise improves blood circulation and reduces the risk of various vascular disorders.
C) Incorrect - Consuming a high-fat diet is not recommended for aneurysm prevention. High-fat diets can contribute to atherosclerosis and other cardiovascular issues.
D) Incorrect - Smoking, even in small amounts, is a significant risk factor for aneurysms. Any amount of smoking should be strongly discouraged for individuals interested in preventing aneurysms and peripheral vascular disorders.
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