A client recovering in the intensive care unit following a percutaneous coronary intervention (PCI) and stent placement is receiving an IV infusion of tirofiban and has a compression device on the right inguinal PCI access site. When the client reports pain at the PCI access site, which action should the nurse take?

Administer an IV narcotic analgesic.

Adjust compression device until client is comfortable.

Turn the client to a left side-lying position.

Assess the femoral PCI access site for a hematoma.

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.

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 C

Explanation

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

A. Ensure supplemental oxygen and respiratory medications are available at all times. B. Use nasal or cough tissues followed by handwashing at all times. C. Avoid large crowded areas during the colder months of the year. D. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.

Correct Answer is D

Explanation

Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.

Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.

Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.

Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.

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

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Correct Answer is D

Explanation

The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?