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 ["A","E","F"]

Explanation

Choice A reason: Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening.
Choice B reason: There is no need to restrict the child to clear liquids for several days unless specifically instructed by the physician for a particular reason. After cardiac catheterization, patients are usually encouraged to resume their normal diet as tolerated to promote recovery unless there are other concerns that warrant dietary restrictions1.
Choice C reason: Avoiding baths or showers is generally recommended immediately after cardiac catheterization to prevent infection at the catheter insertion site. However, this restriction is usually only for a few days, not indefinitely. The site needs to be kept dry and clean until it has sufficiently healed.
Choice D reason: Keeping a pressure dressing on the site for one week is not typically necessary. The dressing is usually checked and changed by healthcare professionals, and the site is monitored for healing. The dressing may be removed after a certain period, often before one week, as long as there are no signs of bleeding or infection.
Choice E reason: Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection.
Choice F reason: The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it’s important to use the correct dosage and to ensure it doesn’t interfere with any other medications the child may be taking.

A. Decreased bowel sounds. B. Increased respiratory rate. C. Increased abdominal girth. D. Decreased level of consciousness.

Correct Answer is C

Explanation

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

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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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