A nurse is caring for an adolescent following a cardiac catheterization.
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.
Apical pulse.
Adolescent's position.
Pulses of right extremity.
Pain.
Pressure dressing.
Respiratory rate.
Blood pressure.
Temperature & appearance of right lower extremity.
Correct Answer : C,E,G,H
Choice A rationale:
The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.
Choice B rationale:
The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.
Choice C rationale:
The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.
Choice D rationale:
The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.
Choice E rationale:
The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.
Choice F rationale:
The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.
Choice G rationale:
The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.
Choice H rationale:
The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.
So, the correct answer is Choice C, E, G, H, after analyzing all choices. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Checking the pulse rate before taking nitroglycerin is not necessary.
Choice B rationale:
Sitting down before taking nitroglycerin can prevent dizziness and fainting, which are potential side effects of nitroglycerin.
Choice C rationale:
There is no need to remove the nitroglycerin patch before taking sublingual nitroglycerin.
Choice D rationale:
The nitroglycerin patch should not be used to treat acute chest pain.
So, the correct answer is B, after analyzing all choices.
Correct Answer is D
Explanation
Choice A rationale:
While a history of heart attack indicates a general risk for heart disease, it is not specifically associated with an increased risk for infective endocarditis.
Choice B rationale:
Immunizations do not typically increase the risk for infective endocarditis.
Choice C rationale:
Family history of endocarditis does not necessarily increase the risk for infective endocarditis.
Choice D rationale:
Dental work can introduce bacteria into the bloodstream, which can lead to infective endocarditis, especially in individuals with prosthetic heart valves.
So, the correct answer is D, after analyzing all choices.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
