A client is recovering in the critical care unit following a cardiac catheterization.

Intravenous (IV) nitroglycerin and heparin are infusing.

The client is sedated but responds to verbal instructions.

After changing positions, the client complains of pain at the right groin insertion site.

Which action should the nurse implement?

Check femoral site for hematoma formation.

Stimulate the client to take deep breaths.

Evaluate the integrity of the IV insertion site.

Assess distal lower extremity capillary refill.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. Assessment of tobacco use geared toward adolescents. B. Exploration of stress self-management techniques. C. Video with statistics showing trends in suicide rates. D. Handouts for local substance abuse treatment centers

Correct Answer is B

Explanation

Choice A rationale:

Assessment of tobacco use geared toward adolescents is an important topic, but it may not directly address the immediate concerns related to the increase in suicides in the community. While substance abuse can be a risk factor for mental health issues, focusing on stress self-management techniques may be more relevant in this context as it can help adolescents cope with various stressors and emotions that could contribute to suicidal thoughts.

Choice C rationale:

Showing statistics on suicide rates may be informative but may not be the most engaging and effective approach to teaching adolescents about mental health. Statistics alone may not provide them with practical tools and strategies to manage their mental well-being.

Choice D rationale:

Providing handouts for local substance abuse treatment centers is important if substance abuse is a concern, but it may not address the broader issue of mental health and suicide prevention. The primary focus should be on teaching adolescents how to manage stress and emotions in a healthy way, as this can be a preventive measure for various mental health issues, including suicidal thoughts.

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Naxlex Comprehensive Predictor Exams

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

Correct Answer is B

Explanation

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.)

Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?