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 A
Explanation
The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.
The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.
Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
Choice C is wrong because it does not acknowledge the son’s need for support or assistance.
It may sound like an empty compliment or a dismissal of the son’s concerns.
The nurse should express empathy and compassion, but also provide information and resources that can help the son.
Choice D is wrong because it does not offer any solution or guidance to the son.
It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.
The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
Correct Answer is B
Explanation
Choice A reason:
Substitute tobacco use with an electronic cigarette Electronic cigarette, also known as e-cigarettes or vapes, are not recommended as a primary treatment for nicotine withdrawal. While they may be considered less harmful than traditional tobacco products, their long-term safety and effectiveness in helping individuals quit smoking are still a subject of debate and research. It is generally better to opt for proven nicotine replacement therapies, such as nicotine gum, patches, lozenges, or other medications approved by healthcare providers for smoking cessation.
Choice B reason:
Limitin use of nicotine gum to 6 months is the correct choice. When discussing treatment options with a client experiencing nicotine withdrawal, the nurse should include the information that the use of nicotine gum should be limited to 6 months. Nicotine gum is a form of nicotine replacement therapy (NRT) used to help individuals quit smoking by reducing withdrawal symptoms and cravings.
However, prolonged use of nicotine gum can lead to its own dependence on nicotine, which is counterproductive to the goal of quitting smoking altogether. The use of NRT is typically recommended for a limited duration, and the goal is to gradually reduce the dosage over time until the individual can comfortably quit nicotine use altogether.
Choice C reason:
Using progressively larger nicotine patches Using progressively larger nicotine patches is not a recommended approach for nicotine withdrawal. Nicotine patches are available in different strengths, and the appropriate dosage should be determined based on the individual's smoking history and nicotine dependence. Starting with the appropriate strength and gradually reducing the dosage over time is the preferred approach to help clients quit smoking.
Choice D reason:
Using up to 40 nicotine lozenges per day the use of nicotine lozenges should be guided by the instructions provided with the product or as prescribed by a healthcare provider. It is not advisable to exceed the recommended dosage. Using excessive amounts of nicotine lozenges or any other NRT product can lead to nicotine toxicity and other adverse effects.
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