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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

A. Emphasize that using safe sex practices removes the risk of STIs. B. Explain that reinfections occur from sex with untreated partners. C. Clarify that all STIs are transmitted through sexual intercourse. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is B

Explanation

Choice A rationale:

Emphasize that using safe sex practices removes the risk of STIs. Rationale: While promoting safe sex practices is essential in preventing STIs, this response is not directly addressing the client's situation. The client already reports having unprotected sex, so this choice does not provide relevant information or address the potential consequences.

Choice B rationale:

Explain that reinfections occur from sex with untreated partners. Rationale: This is the correct response. Syphilis is a sexually transmitted infection that can be treated with antibiotics, but reinfections can occur if sexual partners are not treated. This response provides essential information about the potential consequences of unprotected sex with untreated partners.

Choice C rationale:

Clarify that all STIs are transmitted through sexual intercourse. Rationale: While this statement is accurate in a general sense, it does not specifically address the client's situation or the risks associated with syphilis. It lacks the focus needed to educate the client effectively about their current situation.

Choice D rationale:

Provide counseling that most contraceptives protect against infection. Rationale: This response is inaccurate. Contraceptives primarily aim to prevent pregnancy, not protect against STIs. Therefore, it does not address the client's concern or provide relevant information about syphilis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is B

Explanation

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).