Hesi RN Exit Proctored Exam
A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client reports pain at the right groin insertion site. Which action should the nurse implement?
Explanation & Rationale
A. Evaluating the integrity of the IV insertion site is important for assessing the patency of the IV line, but the client is reporting pain at the groin insertion site specifically. B. Stimulating the client to take deep breaths may help with relaxation but does not address the immediate concern of pain at the groin site. C. Checking the femoral site for hematoma formation is the priority action, as pain at the insertion site may indicate bleeding or hematoma development, which could lead to serious complications. D. Assessing distal lower extremity capillary refill is important for vascular assessment but is secondary to checking the femoral site for potential complications from the catheterization.
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