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 B

Explanation

A. Avoiding sick contacts is generally a good practice, but it is not the primary concern for a client with infective endocarditis. The focus is on preventing bacterial infections that could enter the bloodstream and affect the heart valves.
B. Prophylactic antibiotics are required before dental and invasive procedures to prevent bacterial endocarditis recurrence. The bacteria that cause infective endocarditis can enter the bloodstream through procedures that involve mucosal surfaces.
C. Discontinuing antibiotics when feeling better is incorrect. Infective endocarditis requires a full course of IV antibiotics, often lasting 4 to 6 weeks, to fully eradicate the infection and prevent complications.
D. Avoiding physical activity for six months is unnecessary unless the client has severe cardiac complications. However, clients should monitor for symptoms such as fatigue and consult their provider before engaging in strenuous activities.

A. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. B. Call the provider if you gain 2 lbs. in 24 hours. C. Check weight daily when it is easiest. D. It is okay to skip a dose of diuretic.

Correct Answer is B

Explanation

A. A weight gain of 1 lb in a week may not indicate fluid overload, but a more rapid increase is concerning.
B. A weight gain of 2 lbs in 24 hours or 5 lbs in a week suggests worsening heart failure due to fluid retention, requiring immediate provider notification.
C. Daily weights should be taken at the same time each day, preferably in the morning, after urination and before eating, for accurate monitoring.
D. Skipping a diuretic dose can lead to fluid retention and worsening symptoms, so adherence to the medication regimen is crucial.

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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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