A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client'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. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

Choice A rationale:

Leaving the client alone to give them space is not an appropriate intervention for a client with depression and a history of suicide attempts. Isolation can increase feelings of hopelessness and despair, potentially leading to self-harm or suicidal thoughts.

Choice B rationale:

Removing any potential means of self-harm from the client's environment is the most essential intervention in this scenario. It is crucial to ensure the client's safety by eliminating access to items or substances that could be used for self-harm, such as medications, sharp objects, or other dangerous items. This intervention helps reduce the immediate risk of harm.

Choice C rationale:

Encouraging the client to confront their feelings of hopelessness is important in the long term, as it can be part of therapeutic interventions. However, it should not be the immediate priority when the client is at risk of self-harm. Ensuring their safety is paramount.

Choice D rationale:

Telling the client that they should be grateful for what they have is not an appropriate intervention. It can be perceived as dismissive of their feelings and may worsen their sense of hopelessness and isolation.