Question

A nurse is assessing a client who is 2 hours post-op following a cardiac cath. Report to MD?

A. Capillary refill of 3 seconds.
B. Hematoma at the catheter insertion site.
C. Urinary output of 30 mL/hour.
D. Slight redness at the catheter insertion site.

Answer 1

The nurse should report a hematoma at the catheter insertion site and a urinary output of 30 mL/hour to the physician, as these may indicate more critical post-operative complications requiring attention.

Step-by-step explanation:

In assessing a client who is 2 hours post-operation following a cardiac catheterization, the findings that should prompt a report to the physician include: B. Hematoma at the catheter insertion site and C. Urinary output of 30 mL/hour. Although a capillary refill of 3 seconds (A) might be on the higher end of normal (normal being less than 2 seconds), it is not as immediately concerning as a hematoma, which could indicate internal bleeding or blood collection, or oliguria (low urine output), which may signify renal dysfunction or dehydration post-procedure. Slight redness at the catheter insertion site (D) can be expected post-procedure and does not typically require urgent attention unless accompanied by other signs of infection.