A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

Assess the insertion site.

Keep the client NPO for 4 hr.

Keep the affected leg slightly flexed.

Elevate the head of the bed 45°.

Answer and Explanation

The Correct Answer is A

A. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.

B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.

C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.

D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.

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Correct Answer is B

Explanation

A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.

B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.

C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.

D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.

A. The duration of contact with the agent. B. The type, dose, and length of exposure. C. The pathway of flow through the body. D. The temperature to which the skin is heated.

Correct Answer is B

Explanation

A. The duration of contact with the agent: While duration is important, it alone does not provide a comprehensive understanding of radiation burns, which require considering the type and dose of radiation as well.

B. The type, dose, and length of exposure: These factors are crucial in assessing the severity and necessary treatment for radiation burns. The type of radiation (e.g., alpha, beta, gamma), the dose

received, and the length of exposure all determine the extent of tissue damage and appropriate interventions.

C. The pathway of flow through the body: This is more relevant to internal contamination with radioactive substances rather than external radiation burns.

D. The temperature to which the skin is heated: Temperature is a factor in thermal burns, not radiation burns. Radiation burns result from energy transfer, not heat.

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A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

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Naxlex Comprehensive Predictor Exams

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