A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Monitoring the insertion site for infection

Checking for orthostatic hypotension

Forcing fluids

Immobilizing the affected extremity

None

Answer and Explanation

The Correct Answer is D

A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.

B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.

C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.

D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.

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Correct Answer is B

Explanation

A. Inserting an indwelling catheter is within the LPN’s scope of practice. However, this task should only be delegated if the nurse has verified the need and obtained a provider’s order. Delegation of this task depends on the facility’s policies and the LPN’s competencies.

B. Obtaining abdominal girth is a routine measurement that can be delegated to an AP. This task does not require clinical judgment, making it unnecessary to assign it to the LPN.

C. Assessing and documenting the level of consciousness requires critical thinking and nursing judgment, which are responsibilities of the registered nurse (RN). This task should not be delegated to the LPN or AP.

D. Measuring the amount of gastric drainage every 2 hours is within the scope of practice for the LPN. This task involves observation and documentation but does not require complex clinical judgment, making it an appropriate delegation for the LPN.

A. Decreased serum osmolarity B. Decreased hematocrit C. Elevated blood urea nitrogen (BUN) D. Lower urine specific gravity

Correct Answer is C

Explanation

A. Decreased serum osmolarity: Fluid volume deficit typically leads to an increase in serum osmolarity due to concentration of solutes in the blood, not a decrease.

B. Decreased hematocrit: Dehydration causes hemoconcentration, leading to an increase in hematocrit, not a decrease.

C. Elevated blood urea nitrogen (BUN): Dehydration results in decreased renal perfusion and concentration of urea in the blood, leading to elevated BUN levels.

D. Lower urine specific gravity: Dehydration causes increased urine concentration, resulting in higher urine specific gravity, not lower.

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A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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