A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?
Encourage the client to ambulate within 30 min following the procedure.
Keep the client NPO for at least 2 hr following the procedure.
Assess pulses in the client's affected arm.
Apply light pressure to the insertion site.
The Correct Answer is C
Choice A rationale
Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.
Choice B rationale
Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.
Choice C rationale
Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.
Choice D rationale
Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.
Choice B rationale
The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.
Choice C rationale
Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.
Choice D rationale
Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.
Correct Answer is A
Explanation
Choice A rationale
Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI) due to referred pain from the heart.
Choice B rationale
Shortness of breath can also be associated with MI but is not as specific as radiating pain to the left arm.
Choice C rationale
Headache is not a typical symptom of an MI. It is more commonly associated with other conditions.
Choice D rationale
Nausea and vomiting can occur with an MI but are not as specific as radiating pain to the left arm.
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