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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?

A.

Evaluate the integrity of the IV insertion site.

B.

Encourage the patient to take deep breaths.

C.

Assess distal lower extremity capillary refill.

D.

Inspect the femoral site for hematoma formation.

Answer and Explanation

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


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Related Questions

Correct Answer is ["D","E","F","G"]

Explanation

Based on the provided information, the following aspects of the assessment require urgent attention:

  • The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
  • The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
  • The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
  • The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Choice A rationale

Decreased range of motion is generally associated with a rotator cuff injury. This is because the rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of the upper arm bone firmly within the shallow socket of the shoulder. When these muscles or tendons are injured, it can limit the shoulder’s range of motion.

Choice B rationale

Pain with movement can be a symptom of both a rotator cuff injury and a humeral fracture. Both conditions involve structures that are integral to the movement of the arm, and damage to these structures can cause pain when they are moved or put under strain.

Choice C rationale

Reduced strength in the left upper extremity is more commonly associated with a rotator cuff injury. The rotator cuff is responsible for the stability of the shoulder joint and enables the arm to lift and rotate. An injury to the rotator cuff can therefore lead to a reduction in the strength of the arm.

Choice D rationale

Reduced pulse distal to the injury is more commonly associated with a humeral fracture. This is because a fracture to the humerus could potentially damage the blood vessels running along the bone, leading to a reduced pulse further down the arm.

Choice E rationale

Coolness of the skin is more commonly associated with a humeral fracture. This could be due to damage to the blood vessels, leading to reduced blood flow and therefore a lower skin temperature.

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