One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?
Measure vital signs and telemetry pattern.
Palpate and compare pedal pulse volumes.
Measure post-procedure intake and output.
Remove the dressing and observe the site.
The Correct Answer is A
Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.
Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.
Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.
Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.
Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.
Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.
Correct Answer is A
Explanation
Choice A reason: This is the most immediate and important action to take to prevent the potential spread of COVID-19, especially in a healthcare setting where there is a risk of infecting others.
Choice B reason: While placing the swab in a biohazard bag is a standard procedure, it is not as critical as isolating the patient to prevent transmission.
Choice C reason: Assisting the client to recall contacts is important for contact tracing, but it is secondary to immediate infection control measures within the clinic.
Choice D reason: Educating the client on preventive measures is important, but it does not take precedence over immediate actions to prevent the spread of infection in the clinic.
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