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.

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Correct Answer is C

Explanation

Choice A reason: Feeling emptiness reflects depression but is less urgent than access to firearms in suicidal ideation. Firearms indicate immediate risk, requiring safety planning. Emptiness needs therapy but not priority documentation, per suicide risk assessment and mental health nursing protocols.

Choice B reason: Monthly panic attacks are relevant but not the highest priority in suicidal ideation. Firearm access poses an immediate lethal risk, requiring urgent documentation. Panic attacks are secondary, per suicide risk assessment and psychiatric nursing care standards.

Choice C reason: Documenting firearm access is critical, as it indicates a means for suicide in a client with suicidal ideation. This prompts immediate safety interventions, like removing access, to prevent harm, per suicide risk assessment and patient safety protocols in psychiatric nursing.

Choice D reason: The daughter as a reason to live is protective but less urgent than firearm access, which poses immediate risk. Firearms require priority documentation to ensure safety. This is secondary, per suicide prevention and mental health assessment standards in nursing.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Radial pulse volume is 3+. D. Capillary refill time is 2 seconds.

Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Correct Answer is C

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?