A client is two hours postoperative from a cardiac catheterization via the right femoral artery.
Which assessment finding indicates arterial obstruction?

The right foot is cool to the touch and appears pale and blanched.

The pressure dressing at the right femoral area is moist and oozing blood.

The client’s blood pressure trend is downward, and the pulse is rapid and irregular.

The pulse distal to the femoral artery is weaker on the left foot than the right foot.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.

Choice B rationale

While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.

Choice C rationale

A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.

Choice D rationale

A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.

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Correct Answer is B

Explanation

Choice A rationale

Roast pork is a protein source and does not contribute to fiber content. However, fresh strawberries are high in fiber and may not be suitable for a low-fiber diet.

Choice B rationale

Roasted turkey is a good source of protein and does not contribute to fiber content. Canned vegetables are typically lower in fiber than their fresh or frozen counterparts because the canning process tends to degrade some of the fiber. Therefore, this food selection indicates that the patient understands the prescribed low-fiber diet.

Choice C rationale

Both baked potatoes with skin and raw carrots are high in fiber. The skin of the potato and raw carrots contain insoluble fiber, which may not be suitable for a patient with ulcerative colitis on a low-fiber diet.

Choice D rationale

Pancakes made from refined flour can be part of a low-fiber diet. However, whole-grain cereals are high in fiber and may not be suitable for a patient with ulcerative colitis on a low-fiber diet.

A. Note the presence of an auscultatory gap. B. Continue with the blood pressure assessment. C. Reinflate the cuff to a higher number. D. Reposition the stethoscope over the brachial artery.

Correct Answer is B

Explanation

Choice A rationale

Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.

Choice B rationale

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.

Choice C rationale

Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.

Choice D rationale

Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

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A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

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Naxlex Comprehensive Predictor Exams

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

Correct Answer is B

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After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

Correct Answer is B

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A client is two hours postoperative from a cardiac catheterization via the right femoral artery.
Which assessment finding indicates arterial obstruction?