The nurse assesses a client who just returned to the recovery area after undergoing a balloon angioplasty to improve circulation to the left leg. What assessment finding is the most concerning?

Client reports a pain level of 3/10.

Left groin has minimal bruising.

Left leg with weakened pedal pulse and is cool to the touch.

Blood pressure 154/78 mmHg.

Answer and Explanation

The Correct Answer is C

A. A mild pain level of 3/10 is common after angioplasty and is not immediately concerning.

B. Minimal bruising at the groin is expected after this procedure and is not alarming.

C. A weakened pedal pulse and a cool leg could indicate compromised circulation, which is a serious concern post-angioplasty. Immediate assessment is needed to check for possible complications such as re-occlusion.

D. A blood pressure of 154/78 mmHg is somewhat elevated but not alarming.

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Correct Answer is A

Explanation

A. A 19-year-old client with menorrhagia who has been using superabsorbent tampons and has fever with weakness: This is the correct choice. Fever and weakness in the context of menorrhagia suggest a possible infection (e.g., toxic shock syndrome) or severe blood loss, which requires immediate evaluation and intervention.

B. A 35-year-old client with heavy spotting after having a progestin-containing IUD (Mirena) inserted a month ago: Spotting after IUD insertion is common and does not suggest an immediate threat to the client’s health.

C. A 39-year-old client who is complaining of 4/10 pain after an abdominal hysterectomy: Mild pain after a hysterectomy is expected and not an emergency.

D. A 42-year-old client with secondary amenorrhea who says that her last menstrual cycle was 3 months ago: While secondary amenorrhea requires evaluation, it is not as urgent as a client with signs of possible infection or blood loss.

A. The medication must be given slow intravenous IV push. B. Asystole may occur for a few seconds after administration. C. The medication has a long half life, and therefore the duration of action is very long. D. The onset of action occurs in 5 minutes.

Correct Answer is B

Explanation

A. The medication must be given as a rapid intravenous IV push due to its short half-life not slowly.

B. Asystole is a common and expected response after adenosine administration.

C. Adenosine has a very short half-life, contrary to this statement.

D. The onset of action is immediate, not in 5 minutes.

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The nurse assesses a client who just returned to the recovery area after undergoing a balloon angioplasty to improve circulation to the left leg. What assessment finding is the most concerning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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