Aug 28 ACE NCLEX with Practice Question

August 28, 2024

Wednesday

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A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately to the health care provider (HCP)? Select all that apply.

Bleeding at the catheterization site

Client lying down and quietly watching television

Client taking only sips of fluids

Left foot remarkably cooler than right foot

Urine output of 100 mL since the procedure

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Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not treated immediately.

Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated blood flow) to the extremity and can result in tissue necrosis of the affected area.

(Option 2) The client may lie flat for several hours and is encouraged to engage in quiet activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site.

(Option 3) Although clients are encouraged to drink fluids to flush dyes out of their system and prevent dehydration, decreased fluid intake would not warrant notifying the HCP.

(Option 5) Urine output in this client is above 30 mL/hr and considered to be within the normal range.

Educational objective: If not treated immediately, arterial bleeds can lead to hypovolemic shock and death. Reduced warmth in the lower extremity of the catheter insertion site is a sign of decreased perfusion (lack of oxygenated blood flow).

Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not treated immediately.

Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated blood flow) to the extremity and can result in tissue necrosis of the affected area.

(Option 2) The client may lie flat for several hours and is encouraged to engage in quiet activities for 24 hours after the procedure to prevent dislodging the clot at the insertion site.

(Option 3) Although clients are encouraged to drink fluids to flush dyes out of their system and prevent dehydration, decreased fluid intake would not warrant notifying the HCP.

(Option 5) Urine output in this client is above 30 mL/hr and considered to be within the normal range.

Educational objective: If not treated immediately, arterial bleeds can lead to hypovolemic shock and death. Reduced warmth in the lower extremity of the catheter insertion site is a sign of decreased perfusion (lack of oxygenated blood flow).

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Aug 28 ACE NCLEX with Practice Question

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Aug 28 ACE NCLEX with Practice Question

Aug 28 ACE NCLEX with Practice Question
Aug 28 ACE NCLEX with Practice Question
Aug 28 ACE NCLEX with Practice Question