A patient is recuperating in the critical care unit following a cardiac catheterization.
IV nitroglycerin and heparin are being administered.
The patient is sedated but responds to verbal instructions.
After changing positions, the patient reports pain at the right groin insertion site.
What action should the nurse take?
Evaluate the integrity of the IV insertion site.
Encourage the patient to take deep breaths.
Assess distal lower extremity capillary refill.
Inspect the femoral site for hematoma formation.
The Correct Answer is D
Choice A rationale
Evaluating the integrity of the IV insertion site is important, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice B rationale
Encouraging the patient to take deep breaths can help with overall comfort and oxygenation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice C rationale
Assessing distal lower extremity capillary refill can provide information about the patient’s overall circulation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.
Choice D rationale
Inspecting the femoral site for hematoma formation is the most appropriate action in response to the patient’s complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Ulcerative colitisUlcerative colitis Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
The findings suggest that the client’s condition has improved.
Choice A rationale
A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.
Choice B rationale
A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.
Choice C rationale
The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.
Choice D rationale
A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.
Correct Answer is A
Explanation
Choice A rationale
Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.
Choice B rationale
A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.
Choice C rationale
An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.
Choice D rationale
A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.
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