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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Attach the drainage bag to the bed frame.
Choice A rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.
Choice B rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.
Choice C rationale:
Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.
Choice D rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Correct Answer is B
Explanation
Choice A rationale:
The statement, "This medication will shorten the duration of my symptoms," is correct. Oseltamivir is an antiviral medication used to treat influenza, and it can reduce the duration of symptoms when taken early in the course of the illness.
Choice B rationale:
The statement, "This medication will prevent me from spreading the virus to others," is incorrect. While oseltamivir can help reduce the severity and duration of symptoms, it does not prevent the spread of the virus to others. Clients with influenza should still take precautions to avoid transmitting the virus to others.
Choice C rationale:
The statement, "This medication will work best if I start taking it within 48 hours of symptom onset," is correct. Oseltamivir is most effective when started within 48 hours of the onset of symptoms.
Choice D rationale:
The statement, "This medication may cause nausea and vomiting as side effects," is correct. Nausea and vomiting are potential side effects of oseltamivir, and clients should be informed about these possible adverse reactions.
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