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.

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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Correct Answer is A

Explanation

Choice A rationale

Observing for signs of depression is the most important intervention for the nurse to include in the client’s plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client’s overall well-being and successful outcomes.

A. Remove resuscitation equipment from the room. B. Place a small pillow under the head. C. Take out dentures and place in a labeled cup. D. Apply a body shroud. E. Gently close the eyes.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Removing resuscitation equipment from the room is a standard practice before allowing family members to view the body after an unsuccessful resuscitation. This helps to create a more peaceful and less distressing environment for the family. It also respects the dignity of the deceased and allows the family to focus on their loved one, rather than the medical interventions that were attempted.

Choice B rationale

Placing a small pillow under the head is a common practice in preparing the body for viewing by the family. This helps to position the body in a natural and peaceful manner, which can be comforting for the family. It also respects the dignity of the deceased.

Choice E rationale

Gently closing the eyes is another common practice in preparing the body for viewing by the family. This helps to give the appearance of peaceful rest, which can be comforting for the family. It also respects the dignity of the deceased.

Choice C rationale

Taking out dentures and placing them in a labeled cup is not a standard practice in preparing the body for viewing by the family. Dentures, if present, are usually left in place to maintain the natural appearance of the face.

Choice D rationale

Applying a body shroud is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A child weighing 55 lb has been prescribed cefotaxime at a dosage of 150 mg/kg/day, to be administered in divided doses every 6 hours. How many mg should the nurse administer each day? (Provide a numerical value only.)

Which client statement or behavior is most likely associated with their current condition?

A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.Who should be contacted to manage the progression of the patient’s care?

When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?