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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A murmur is the expected heart sound in mitral valve regurgitation, caused by the backflow of blood into the left atrium during systole. It is typically a holosystolic murmur heard best at the apex of the heart.
B. S3 and S4 heart sounds may be heard in heart failure but are not specific for mitral regurgitation.
C. A friction rub is associated with pericarditis, not valvular disease.
D. A click is typically heard in mitral valve prolapse, not mitral regurgitation.
Correct Answer is D
Explanation
A. Complete heart block (third-degree AV block) is characterized by a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently of each other.
B. Sinus tachycardia presents with a regular rhythm, a heart rate above 100 beats per minute, and distinct P waves preceding each QRS complex.
C. Idioventricular rhythm occurs when the heart's primary pacemakers fail, leading to a slow ventricular rate (usually 20-40 bpm) with wide QRS complexes and no preceding P waves.
D. Ventricular tachycardia (VT) is a life-threatening arrhythmia characterized by a rapid ventricular rate (typically >100 bpm), wide QRS complexes, and an absence of P waves. VT can be sustained or non-sustained and may require immediate intervention if the patient is unstable.
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