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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Going to the ER for glucose is unnecessary unless hypoglycemia or ketoacidosis is confirmed. Type 1 diabetes with nausea risks hyperglycemia from stress hormones like cortisol. Monitoring glucose and fluids manages the condition at home, preventing escalation unless severe symptoms arise, making this instruction premature.
Choice B reason: Drinking regular cola introduces high sugar, risking hyperglycemia in type 1 diabetes, where insulin deficiency impairs glucose uptake. Stress from illness elevates glucose via glucagon. Monitoring with non-sugar fluids prevents dehydration and ketoacidosis, making this advice dangerous and ineffective for diabetes management.
Choice C reason: Monitoring blood glucose and drinking fluids is critical in type 1 diabetes during illness. Nausea reduces intake, and stress hormones raise glucose, risking ketoacidosis. Frequent checks guide insulin adjustments, and fluids prevent dehydration, maintaining metabolic stability, addressing the physiological needs of insulin deficiency and infection.
Choice D reason: Avoiding insulin risks diabetic ketoacidosis, as type 1 diabetes requires basal insulin despite nausea. Illness increases glucose via stress hormones, even without food. Monitoring allows tailored dosing, preventing hyperglycemia, making this instruction harmful, as it ignores ongoing insulin needs for metabolic control.
Correct Answer is C
Explanation
Choice A reason: Measuring abdominal girth monitors distention but is less critical before digital removal of a fecal impaction. Impaction causes constipation, but girth changes are slow. Vital signs detect autonomic responses like bradycardia from vagal stimulation during the procedure, making them more urgent to ensure safety.
Choice B reason: Bowel sounds indicate motility, reduced in impaction, but do not predict complications during digital removal, which risks vagal stimulation causing bradycardia. Vital signs are critical, detecting cardiovascular instability, ensuring safety during this invasive procedure, making bowel sounds less immediate for assessment.
Choice C reason: Assessing vital signs is essential, as digital removal stimulates rectal nerves, potentially triggering a vagal response, causing bradycardia or hypotension. This risks syncope or shock. Monitoring heart rate and blood pressure ensures cardiovascular stability, preventing complications during this procedure, addressing autonomic risks effectively.
Choice D reason: Breath sounds assess respiratory status, unrelated to fecal impaction removal, a gastrointestinal issue. The procedure risks vagal stimulation, not pulmonary effects. Vital signs detect cardiovascular changes like bradycardia, ensuring safety during rectal manipulation, making breath sounds irrelevant for this assessment.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.