A client returns to his room following a cardiac catheterization. Which of the following assessments, if made by the nurse, would justify calling the health care provider?
1. Absence of pulse distal to the catheter insertion site
2. Pain at the site of the catheter insertion
3. Drainage on the dressing covering the catheter insertion site
4. Redness at the catheter insertion site
Absence of pulse distal to the catheter insertion site
Rationale: Absence of a pulse distal to the catheter insertion site indicates clot formation in the artery. The health care provider needs to be notified so measures can be taken to remove the clot and restore tissue perfusion. Pain, some drainage, and redness are all expected following the insertion of a catheter.
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