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A
Pain tolerance
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B
Assess the puncture site and affected extremity every 15 minutes for bleeding, hematoma, pulses, color, temperature, capillary refill, sensation, and movement — the femoral artery site is at high risk for hemorrhage and vascular complications
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C
The client's mood
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D
Weight
Why this is the answer
CARDIAC CATHETERIZATION via FEMORAL ARTERY ACCESS introduces a large catheter into the femoral artery. After removal, a small hole is left in a major artery — HEMORRHAGE and VASCULAR COMPLICATIONS are the primary post-procedure risks. PRIORITY POST-PROCEDURE ASSESSMENTS: SITE INSPECTION: bleeding (check directly and under the client — blood can pool under the client undetected); hematoma (expanding lump/discoloration at site — concerning if rapidly enlarging or causing neurovascular compromise); NOTE: femoral access requires the client to keep the leg STRAIGHT and LIMIT movement for the prescribed period (typically 2-6 hours depending on closure method); VASCULAR STATUS of the affected extremity: PULSES (dorsalis pedis and posterior tibial pulses distal to the site — check every 15 minutes initially); CIRCULATION: COLOR (pale = arterial occlusion; cyanotic = venous obstruction); TEMPERATURE (should be warm — cold = reduced perfusion); CAPILLARY REFILL (<3 seconds = adequate); SENSATION AND MOVEMENT (numbness, tingling, weakness = neurovascular compromise). FREQUENCY: typically every 15 minutes for the first hour, every 30 minutes for the next hour, then every hour. COMPLICATIONS TO DETECT: BLEEDING: may be external or internal (retroperitoneal hematoma — may not be visible but presents with flank/back pain, hypotension, tachycardia, dropping H&H); ARTERIAL OCCLUSION: absent or diminished distal pulse, pain, pallor, paresthesia, paralysis — 'the 5 P's of arterial occlusion'; PSEUDOANEURYSM: pulsatile mass at site; ARTERIOVENOUS FISTULA: palpable thrill at site; VASOVAGAL: hypotension, bradycardia, nausea. REPORT TO RN: any absent or diminishing distal pulse; expanding hematoma; bleeding that doesn't stop with pressure; hypotension or tachycardia; extremity pallor, cyanosis, or coldness.
Source: NCLEX-PN Test Plan: Physiological — Reduction of Risk, Post-Catheterization