One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Measure vital signs and telemetry pattern.

Palpate and compare pedal pulse volumes.

Measure post-procedure intake and output.

Remove the dressing and observe the site.

Answer and Explanation

The Correct Answer is A

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

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Correct Answer is A

Explanation

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

A. Advise the client to discuss the medication's side effects with the healthcare provider. B. Remind the client that feeling better indicates the therapeutic effect of the medication. C. Inform the client that gradual tapering is necessary to discontinue the medication. D. Assure the client that the medication's side effects will likely dissipate over time. E. None F. None

Correct Answer is A

Explanation

Choice A reason:When a client expresses concerns about medication, especially antidepressants, the nurse should encourage open communication with the healthcare provider. The provider can assess the situation, address side effects, consider adjusting the dosage, or explore alternative medications if needed.

Choice B reason: Reminding the client of the therapeutic effects is helpful for understanding the benefits of the medication, but it does not provide guidance on how to safely discontinue it.

Choice C reason:Tapering is essential for discontinuation, but it should be done under medical supervision. The nurse should first encourage the client to speak with their provider rather than assuming immediate discontinuation.

Choice D reason: While side effects may dissipate over time, this does not provide a solution for the client who wishes to stop the medication now. It is also not guaranteed that all side effects will diminish.

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One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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