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 A
Explanation
Choice A rationale:
An irregular pulse could indicate that myocarditis is affecting the heart’s electrical system, leading to an irregular heartbeat or arrhythmia. This could potentially affect the action of digoxin, a medication used to treat heart conditions, and therefore should be communicated to the healthcare provider.
Choice B rationale:
Leukocytosis, or a high white blood cell count, can be a sign of infection or inflammation, including myocarditis. However, it is not as specific as an irregular pulse in indicating a potential issue with the administration of digoxin.
Choice C rationale:
Generalized myalgia, or muscle pain, can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
Choice D rationale:
Fatigue can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
So, the correct answer is A, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
A fasting triglyceride level of 167 mg/dL is above the desirable level of less than 150 mg/dL, indicating a higher risk for CAD34.
Choice B rationale:
An HDL level of 96 mg/dL is considered good and is protective against CAD34.
Choice C rationale:
An LDL level of 104 mg/dL is near optimal/above optimal, but it’s not high enough to be a priority risk factor for CAD34.
Choice D rationale:
Total serum cholesterol of 192 mg/dL is within the desirable range of less than 200 mg/dL34.
So, the correct answer is A, 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.
