A client has undergone a right femoral cardiac catheterization. What nursing action is the priority following the procedure?
Complete a neurovascular check of the affected extremity.
Perform passive range of motion.
Assess the gag reflex prior to feeding the client.
Keep the client in high Fowler's position.
The Correct Answer is A
A. Complete a neurovascular check of the affected extremity: Neurovascular assessment ensures that blood flow and nerve function are intact post-procedure. Complications such as arterial occlusion or hematoma can cause ischemia or nerve damage, making this the priority.
B. Perform passive range of motion: This is not a priority and may not be appropriate immediately post-catheterization as movement of the extremity can increase the risk of bleeding.
C. Assess the gag reflex prior to feeding the client: This applies to clients recovering from sedation during procedures like endoscopy, not cardiac catheterization.
D. Keep the client in high Fowler's position: This is contraindicated post-cardiac catheterization, as elevating the head too much can increase pressure at the puncture site and lead to bleeding.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. "It is an amino acid which reflects damage to the endothelial lining of arteries." BNP is not related to endothelial damage.
B. "It is a substance composed of free fatty acids reflective of atherosclerosis." BNP is not composed of free fatty acids, and it does not reflect atherosclerosis.
C. "It is a reliable indicator of the presence of heart failure." BNP is a hormone released by the heart in response to increased pressure and volume. Elevated levels of BNP are commonly used as a diagnostic marker for heart failure, especially during exacerbations or decompensation.
D. "It is a protein produced by the liver in response to systemic inflammation." BNP is produced by the heart, not the liver.
Correct Answer is A
Explanation
A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.
B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.
C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.
D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.
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