The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

The pressure dressing at right femoral area is moist and oozing blood.

Pulse distal to the femoral artery is weaker on left foot than right foot.

Right foot is cool to the touch and appears pale and blanched.

Blood pressure trend is downward and pulse is rapid and irregular.

Answer and Explanation

The Correct Answer is C

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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Correct Answer is D

Explanation

Rationale

A. Herpes simplex virus type II (HSV-II) primarily spreads through direct contact with the lesions and is not airborne. Airborne precautions and negative airflow rooms are not necessary for this condition.

B. Scarlet fever is caused by Group A Streptococcus bacteria and typically spreads through respiratory droplets. However, scarlet fever itself does not require airborne precautions. If complicated with pneumonia, respiratory droplets could potentially spread the infection, but specific airborne precautions are generally not required unless there are other pathogens involved that require it.

C. Scabies is caused by the Sarcoptes scabiei mite and spreads through direct skin-to-skin contact. It does not require airborne precautions or negative airflow rooms.

D. Apositive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) suggest tuberculosis (TB) infection. TB is spread through airborne droplets (e.g., coughing, sneezing), and therefore, requires airborne precautions including negative airflow rooms to prevent transmission to others.A

A. Increase rate of ventilation. B. Decrease expiratory flow time. C. Increase ventilator tidal volume. D. Decrease expiratory pressure.

Correct Answer is A

Explanation

Rationale

A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.

B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.

C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.

D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.

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The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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