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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
Correct Answer is A
Explanation
Choice A rationale
The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.
Choice B rationale
While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore
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