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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

A. Washing for a total of 20 seconds. B. Turning the water off using bare hands. C. Holding hands below elbows when rinsing. D. Lathering using a circular movement.

Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

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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?

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Naxlex Comprehensive Predictor Exams

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