- A nurse is caring for an adolescent following a cardiac catheterization. Nurses' Notes
0700
Adolescent alert and oriented, resting in bed in supine position with their legs straight. Pressure dressing to right femoral area dry and intact. Bilateral lower extremities warm to touch with
equal posterior tibial and dorsalis pedis pulses palpated. Reports pain as 0 on a scale of 0 to 10. 0730:
Adolescent awake, resting in supine position with their legs straight. Dressing to right femoral area saturated with bloody drainage. Posterior tibial and dorsalis pedis pulses of right extremity slightly diminished compared to the left extremity Right lower extremity cool and pale in color. Reports pain as 2 on a scale of 0 to 10.
Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.
Right lower extremity color and warmth
Blood pressure
Respiratory rate
Adolescent's position
Pulses of right extremity
Pressure dressing
Pain
Apical pulse
Correct Answer : A,E,F,G
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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