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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.

Choice B rationale

Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.

Choice C rationale

Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.

Choice D rationale

Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.

Choice E rationale

Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.

A. Watery diarrhea. B. Increased fatigue. C. Nausea and headache. D. Yellow-tinged sputum.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

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

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?

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?