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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.
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