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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypertension is not typically a sign of heart failure related to cor pulmonale. It is more associated with systemic issues rather than pulmonary complications.
Choice B rationale
Peripheral edema is a common sign of heart failure and cor pulmonale due to increased pressure in the venous system, leading to fluid accumulation in the tissues.
Choice C rationale
Increased respiratory rate may occur but is not specific to heart failure in cor pulmonale.
Choice D rationale
Cough with pink-tinged sputum is more indicative of pulmonary edema related to left-sided heart failure rather than cor pulmonale.
Correct Answer is A
Explanation
Choice A rationale
The inability to locate a dorsalis pedis pulse and increasing pain indicate compromised circulation, which requires immediate attention to prevent complications.
Choice B rationale
Pain relieved after administering medication indicates effective pain management, which is not an urgent issue to report immediately.
Choice C rationale
Generalized weakness and increasing sensitivity to touch can be concerning but are not as urgent as signs of compromised circulation.
Choice D rationale
Localized edema and discoloration are expected findings in a fracture and are not as urgent as an absent pulse. .
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