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 C

Explanation

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

A. Glaucoma. B. Heart block. C. Gastric ulcers. D. Diabetes mellitus.

Correct Answer is B

Explanation

Choice A reason: Glaucoma is not directly related to the administration of lidocaine, as it does not affect intraocular pressure or the pathophysiology of glaucoma.

Choice B reason: Heart block is a type of arrhythmia where the electrical signal is delayed or blocked entirely. Since lidocaine affects cardiac conduction, it is crucial to review the medical record for heart block before administration.

Choice C reason: Gastric ulcers are not typically a concern when administering lidocaine, as it does not have gastrointestinal effects when given parenterally.

Choice D reason: Diabetes mellitus is not a contraindication for lidocaine administration; however, monitoring blood glucose levels is always important in diabetic patients receiving any medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

Correct Answer is B

Explanation

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