Question

Nurse is caring for a patient one hour following cardiac Cath. The nurse notes formation of hematoma at insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurses priority?

A. Initiate oxygen at 2L/MIN via nasal cannula
B. Apply firm pressure to the insertion site
C. Take patient vital signs
D. Obtain stat order for a PTT

Answer 1

Applying firm pressure to the hematoma site is the nurse's priority after cardiac catheterization to control bleeding and ensure adequate blood flow in the affected extremity.

Step-by-step explanation:

The nurse's priority should be to address the potential complication of the cardiac catheterization procedure, which appears to be a hematoma at the insertion site, accompanied by a decreased pulse in the affected extremity. The most immediate action should be to apply firm pressure to the site of the hematoma to prevent further bleeding. While initiating oxygen and monitoring vital signs are important, they are not as immediate as the need to control the hemorrhage at the insertion site. A decreased pulse rate in the affected extremity could indicate a serious obstruction in blood flow, requiring prompt physical intervention. After stabilizing the site and ensuring the patient's safety, the nurse can perform additional interventions such as checking vital signs and obtaining further medical orders.