A nurse is caring for a client post-cardiac catheterization with a right radial artery puncture site. The nurse performs which priority assessment on arrival to the unit?

Place a pressure dressing over the site.

Have the client flex and extend the right wrist.

Place the patient on oxygen.

Assess the trans-radial (TR) band.

Answer and Explanation

The Correct Answer is D

A. A pressure dressing is already in place following the procedure, and additional dressing is not the priority. Instead, monitoring the TR band for bleeding or complications is essential.
B. Having the client flex and extend the right wrist is not recommended immediately after a radial artery catheterization, as movement can increase the risk of bleeding.
C. Oxygen therapy is not routinely required unless the client has hypoxia or respiratory distress.
D. Assessing the trans-radial (TR) band is the priority to ensure proper hemostasis at the puncture site, monitor for bleeding, and check distal circulation to the hand.

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Correct Answer is C

Explanation

A. An INR of 2 is within the therapeutic range for anticoagulation but is more relevant for warfarin therapy rather than heparin.
B. An aPTT of 80 seconds is slightly elevated but not immediately life-threatening. The therapeutic range for heparin is typically 1.5 to 2.5 times the normal value (approximately 60-80 seconds).
C. Sudden weakness of one arm and leg suggests a possible embolic stroke, which is a serious complication of atrial fibrillation. This requires immediate assessment and intervention.
D. An irregular heart rate without P waves is characteristic of atrial fibrillation but is not the most urgent concern compared to potential stroke symptoms.

A. Elevated Troponins B. Elevated Hemoglobin C. Elevated B-type Natriuretic Peptide (BNP) D. Elevated Creatine Kinase (CK)

Correct Answer is A

Explanation

A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.

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A nurse is caring for a client post-cardiac catheterization with a right radial artery puncture site. The nurse performs which priority assessment on arrival to the unit?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with atrial fibrillation who is receiving continuous IV heparin. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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