A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.
Which of the following actions should the nurse take?
Encourage the client to ambulate within 30 min following the procedure.
Keep the client NPO for at least 2 hr following the procedure.
Assess pulses in the client's affected arm.
Apply light pressure to the insertion site.
The Correct Answer is C
Choice A rationale
Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.
Choice B rationale
Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.
Choice C rationale
Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.
Choice D rationale
Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While swimming can be less likely to trigger asthma attacks than some other sports, children with asthma should not necessarily stop playing basketball if it's something they enjoy. Proper management and understanding triggers are crucial.
Choice B rationale
Avoiding triggers that cause an asthma attack is a fundamental part of asthma management. Triggers can vary from person to person and may include allergens, smoke, cold air, and exercise.
Choice C rationale
The peak expiratory flow meter should be used regularly, typically twice a day, to monitor asthma control, not just once per week. Regular use helps identify worsening symptoms early.
Choice D rationale
Cromolyn sodium is a preventive medication and should be taken regularly as prescribed, not just at the first sign of breathing difficulty.
Correct Answer is C
Explanation
Choice A rationale
Hypertension is not a typical finding associated with community-acquired pneumonia. The condition more commonly presents with respiratory symptoms such as cough, fever, and difficulty breathing.
Choice B rationale
Unequal pupils are not a common finding in community-acquired pneumonia and could indicate a neurological issue or head injury, which would require further investigation.
Choice C rationale
Confusion, particularly in older adults, can be a symptom of community-acquired pneumonia. It is often due to hypoxia or systemic inflammation and is a sign of a more severe infection.
Choice D rationale
Tympany upon chest percussion is not expected in pneumonia. Pneumonia typically presents with dullness on percussion due to the consolidation of lung tissue, not the hyperresonance that causes tympany.
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