A nurse is assessing a client immediately following a cardiac catheterization.
The nurse should notify the provider for which of the following findings?
Heart rate 90/min.
Hematoma over the insertion site.
Bounding pulses in the affected extremity.
Report of discomfort at the insertion site continue.
The Correct Answer is B
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because heart rate 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed, but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, frequent swallowing.
This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.
Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.
Drowsiness can be caused by anesthesia, medication, or dehydration.
Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.
Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.
Normal ranges for plasma clotting variables depend on the specific test and method used.
Correct Answer is C
Explanation
Choice A option
Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.
Choice B option
PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.
Choice C option
The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.
Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.
Choice D option
Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.
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