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 B
Explanation
Choice A rationale:
Beginning continuous observation for transient episodes of neurologic dysfunction is important in the assessment and monitoring of the client's condition. However, in this scenario, the client is presenting with symptoms suggestive of a possible stroke or cerebrovascular event, and time is crucial. The nurse should prioritize actions that can lead to prompt diagnosis and treatment.
Choice B rationale:
Starting two large bore intravenous (IV) catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the most urgent action. The client's symptoms, including sudden right-sided numbness, weakness, and facial droop, are indicative of a possible ischemic stroke. IV fibrinolytic therapy is time-sensitive and has a limited window of effectiveness. Establishing IV access and determining eligibility for this therapy should be the nurse's top priority to potentially improve the client's outcome.
Choice C rationale:
Administering aspirin to prevent further clot formation and platelet clumping is an important intervention in the treatment of ischemic stroke. However, it should not be the first action in this scenario. The priority is to assess for eligibility for IV fibrinolytic therapy, as this intervention has a more immediate impact on reversing the stroke's effects.
Choice D rationale:
Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is a reasonable nursing intervention to prevent complications such as aspiration and promote optimal cerebral blood flow. However, it is not the most urgent action in this case. The priority should be on assessing and potentially treating the stroke with IV fibrinolytic therapy.
Correct Answer is A
Explanation
Choice A rationale:
Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.
Choice B rationale:
Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.
Choice C rationale:
While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.
Choice D rationale:
Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.
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