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","E"]

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

A. Encourage the client to obtain a complete physical exam, as these symptoms are consistent with an ulcer. B. Advise the client to seek immediate medical evaluation and treatment for these symptoms. C. Instruct the client that these mild symptoms can generally be controlled with changes in the diet. D. Assure the client that the symptoms may only reflect reflux, since ulcer pain is not relieved by food.

Correct Answer is A

Explanation

Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.

Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.

Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.

Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.

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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

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