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A nurse is caring for a client post cardiac catheterization via the right groin site. The nurse is aware that which of the following findings needs to be reported to the interventional cardiologist as soon as it is identified.

Swelling at the insertion site and cool extremity

Oozing blood from the insertions site

The client has not voided since returning to recovery.

Blood pressure reading of 110/70 and heart rate of 90

Answer and Explanation

The Correct Answer is A

Rationale:

A. Swelling at the insertion site and cool extremity may indicate bleeding or hematoma formation at the site.

B. Oozing blood from the insertion site is expected immediately after a cardiac catheterization.

C. The client has not voided since returning to recovery is not related to the cardiac catheterization.

D. Blood pressure reading of 110/70 and heart rate of 90 are within normal limits.

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Correct Answer is B

Explanation

Rationale:

A. This describes a second-degree heart block, specifically Mobitz Type I (Wenckebach).

B. A PR interval greater than 0.20 seconds is characteristic of first-degree heart block.

C. This describes third-degree heart block, also known as complete heart block.

D. An irregular R-R interval is not specific to first-degree heart block.

A. Look for P waves on the strip B. Count how many QRS occur in a 6 second strip C. Read the monitor or electrocardiogram interpretation. D. Measure the T waves

Correct Answer is B

Explanation

Rationale:

A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.

B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.

C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.

D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.

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A nurse is caring for a client post cardiac catheterization via the right groin site. The nurse is aware that which of the following findings needs to be reported to the interventional cardiologist as soon as it is identified.

Nursing Test Bank

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