A patient is recuperating in the critical care unit following a cardiac catheterization.
IV nitroglycerin and heparin are being administered.
The patient is sedated but responds to verbal instructions.
After changing positions, the patient reports pain at the right groin insertion site.
What action should the nurse take?

Evaluate the integrity of the IV insertion site.

Encourage the patient to take deep breaths.

Assess distal lower extremity capillary refill.

Inspect the femoral site for hematoma formation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Evaluating the integrity of the IV insertion site is important, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice B rationale

Encouraging the patient to take deep breaths can help with overall comfort and oxygenation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice C rationale

Assessing distal lower extremity capillary refill can provide information about the patient’s overall circulation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice D rationale

Inspecting the femoral site for hematoma formation is the most appropriate action in response to the patient’s complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Ulcerative colitisUlcerative colitis Explore

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Correct Answer is A

Explanation

Choice A rationale

Watery diarrhea is a significant side effect of linezolid and could indicate a serious condition called antibiotic-associated colitis, which is caused by an overgrowth of the bacterium Clostridium difficile. This condition requires immediate medical attention.

Choice B rationale

Increased fatigue is a common side effect of many medications, including linezolid. While it should be reported to the healthcare provider, it is not as urgent as watery diarrhea.

Choice C rationale

Nausea and headache are common side effects of linezolid. While they should be reported to the healthcare provider, they are not as urgent as watery diarrhea.

Choice D rationale

Yellow-tinged sputum could indicate an infection or other lung condition. However, in the context of a patient receiving linezolid for nosocomial pneumonia, it is not as urgent as watery diarrhea.

A. Ask the patient how often episodes of sundowning are experienced. B. Inquire about the frequency of falls in recent months. C. Request the patient to lie as still as possible for the assessment. D. Assist the patient with clarifying values about end-of-life care options.

Correct Answer is B

Explanation

Choice A rationale

Asking the patient how often episodes of sundowning are experienced is more relevant in assessing cognitive function, particularly in patients with dementia. It is not directly related to the patient’s weight loss or decreased energy and appetite.

Choice B rationale

Inquiring about the frequency of falls in recent months is crucial in a functional assessment of an older patient who has lost weight and reports a decrease in energy and appetite. Weight loss and decreased energy can increase the risk of falls, which can lead to serious injuries and further functional decline.

Choice C rationale

Requesting the patient to lie as still as possible for the assessment is not directly related to the patient’s weight loss or decreased energy and appetite. It might be necessary for certain physical examinations or procedures, but it is not the most relevant action in this context.

Choice D rationale

Assisting the patient with clarifying values about end-of-life care options is an important aspect of geriatric care, especially in patients with serious illnesses. However, it is not directly related to the patient’s weight loss or decreased energy and appetite.

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Naxlex Comprehensive Predictor Exams

A patient is receiving linezolid IV for nosocomial pneumonia.Which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

Correct Answer is B

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

The nurse observes that a client with ascites is dyspneic.Which action should the nurse implement first?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

The nurse is caring for a child with mononucleosis.Which symptoms should the nurse expect the child to exhibit?

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.