Practice Question
A nurse is caring for an adolescent following a cardiac catheterization.
Answer Choices:
Correct Answer:
Right lower extremity color and warmth
Rationale:
🔶 A. Right lower extremity color and warmth
🔶 A cool and pale extremity indicates compromised peripheral perfusion, likely due to arterial obstruction or bleeding at the catheter insertion site.
🔶 This is a critical finding because it may indicate arterial occlusion, hematoma formation, or impaired circulation.
🔶 Early recognition is essential to prevent limb ischemia, which can lead to long-term complications.
🔶 The affected limb should be warm and pink, not pale and cool, following catheterization.
🔶 Immediate provider notification is necessary to initiate vascular or surgical intervention if needed.
🔶 E. Pulses of right extremity
🔶 Diminished peripheral pulses on the side of the catheter insertion suggest vascular compromise or internal bleeding.
🔶 This indicates impaired arterial blood flow, which may result from thrombosis, embolization, or vessel trauma during the procedure.
🔶 Comparing bilateral pulses is crucial; a decrease on one side must be addressed urgently.
🔶 Weak or absent pulses are a red flag for post-catheterization complications.
🔶 Prompt provider communication is necessary for possible doppler evaluation or imaging.
🔶 F. Pressure dressing
🔶 A saturated pressure dressing is a clear indicator of ongoing bleeding at the catheter insertion site.
🔶 Bleeding at the femoral site can lead to hematoma, hypovolemia, or retroperitoneal hemorrhage if not addressed.
🔶 The dressing should remain dry and intact; saturation compromises the effectiveness of hemostasis.
🔶 This finding requires immediate intervention, including applying pressure and notifying the provider.
🔶 Frequent monitoring of the site and vital signs is necessary after detection.
🔶 G. Pain
🔶 An increase in pain, even if slight, especially localized to the catheterized limb, can indicate ischemia or internal bleeding.
🔶 New or escalating pain post-procedure is concerning when paired with changes in color, pulse, or dressing status.
🔶 While a pain level of 2/10 might not typically warrant concern, in this context, it supports the presence of a complication.
🔶 Pain can result from tissue hypoxia or pressure from a hematoma at the site.
🔶 It should be considered alongside other findings and reported promptly.
Want to practice more questions like this?
This question is from RN ATI Pediatrics Simmons Bsn Exam I which contains 12 questions.
More Questions from This Exam
A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?
Answer Choices:
A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.)
Answer Choices:
A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Answer Choices:
A mother with sickle anemia asks the nurse why her child's hemoglobin was normal at birth and now the child has the S hemoglobin (sickle cell). Which of the following is an appropriate response from the nurse?
Answer Choices:
A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 8