The nurse is checking on the patient who underwent cardiac catheterization via the femoral artery 2 hours after the procedure. The patient appears to be sleeping and the nurse notes that the bruise at the insertion site has increased in size since the last assessment. Which action does the nurse take first?

Check the carotid pulse. The patient is at an increased risk for severe bleeding following a cardiac catheterization. Therefore, the nurse must prioritize the assessment to determine if the patient is in imminent danger of exsanguination by checking the carotid pulse. If the carotid pulse is adequate in rate and intensity, the nurse can then assess the pedal pulse distal to the insertion site to ensure adequate blood flow is reaching the extremity. Evaluation of capillary refill time can be performed if the carotid pulse is weak, thready, and/or rapid. Palpation of the insertion site for a hematoma is likely not advised due to the risk for disruption of clot formation and further bleeding.

The nurse is checking on the patient who underwent cardiac cathet...

Category: Physiological Adaptation
Difficulty: 6

Topics: Cardiovascular Disease Prevention Hematology/Oncology

Want help? View the answer with rationale.

Additional Physiological Adaptation Questions

The 3-week-old neonate has failed to return to birth weight due to projectile vomiting partially-digested breast milk after most feedings. Upon assessment, an olive-shaped mass is palpated in the upper right abdominal quadrant. The nurse anticipates which diagnosis?

Question Type: Multiple Choice - Select One
Difficulty: 4

The 58-year-old patient presents to the emergency department complaining of worsening back pain that started a few days ago. He states, “I thought maybe I had slept wrong and gotten a spasm, but I’m not sure. I didn’t fall or get hit or anything. The ibuprofen I took definitely didn’t help.” His blood pressure is 174/96 mmHg and heart rate is 96 bpm. He reports being out of his antihypertensive medication for the past week while he was out of town. Other history is notable for arthritis in the hands and a 44-pack-year smoking history. He drinks socially but denies illicit drug use. Which assessment is most important?

Question Type: Multiple Choice - Select One
Difficulty: 9

The 38-year-old gravida 1 para 1 patient presents to the clinic in the 8th week of gestation.The patient’s fasting blood sugar test result is 130 mg/dL. The nurse anticipates which diagnosis?

Question Type: Multiple Choice - Select One
Difficulty: 6

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Physiological Adaptation Questions

Nursing Careers

Nursing Degrees

NCLEX