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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale
A. Finish the procedure is rooted in the fundamental nursing principle of patient abandonment and the ABC (Airway, Breathing, Circulation) priority framework.
B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.
C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.
D. You cannot leave one life-threatening situation (a compromised airway) to attend another, especially when a specialized team is already being activated for the code.
Correct Answer is D
Explanation
Rationale
A. Iron-rich meats are beneficial for overall health, particularly for maintaining hemoglobin levels in the blood. However, they are not specifically known for their role in preventing osteoporosis. Iron is important for transporting oxygen in the blood but does not directly impact bone health.
B. Fresh fruits and vegetables are excellent sources of vitamins, minerals, and antioxidants. They contribute to overall health and well-being but are not specifically known for their direct impact on bone health unless they are rich in certain nutrients like vitamin C (found in citrus fruits and peppers) and vitamin K (found in leafy greens like spinach and kale), which can indirectly support bone health.
C. Water is essential for overall hydration and health, but it does not provide specific nutrients directly beneficial for bone health. Herbal teas can contribute to hydration and provide some antioxidant benefits, but they do not have a direct impact on osteoporosis prevention.
D. Low-fat dairy products such as milk, yogurt, and cheese are rich sources of calcium and vitamin D, which are crucial for bone health. Calcium is a primary mineral in bones, and vitamin D helps the body absorb calcium. These nutrients are essential for maintaining bone density and strength, thereby reducing the risk of osteoporosis.
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