A client with a femoral arterial sheath is admitted to the cardiac care unit (CCU) after a percutaneous transluminal coronary angioplasty (PTCA). Which intervention should the nurse provide during the first hour of postoperative care?

Elevate affected extremity to promote venous drainage.

Maintain the head of the bed at a 90 degree angle.

Maintain the heparin infusion distal to the access site.

Remove pressure device at arterial site post 12 hours.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Elevate affected extremity to promote venous drainage: Elevating the leg after femoral arterial access can increase the risk of bleeding or hematoma formation. The affected extremity should remain flat and immobile initially.

B. Maintain the head of the bed at a 90 degree angle: Raising the head of the bed to 90 degrees can increase femoral artery pressure and risk bleeding. The head should be elevated minimally (usually <30°) while keeping the leg straight.

C. Maintain the heparin infusion distal to the access site: Heparin therapy is commonly continued after PTCA to prevent thrombosis at the coronary site. Ensuring anticoagulation is maintained while monitoring the arterial access site is essential during the first postoperative hour.

D. Remove pressure device at arterial site post 12 hours: Pressure devices or closure devices are typically removed per protocol, often within a few hours, not strictly at 12 hours. Timing is determined by institutional protocol and the patient’s hemodynamic stability.

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Correct Answer is B

Explanation

Rationale:
A. Call the chaplain to encourage the wife to wait outside of the room: While spiritual support is valuable, involving a chaplain does not immediately address the safety and efficiency needs during a life-threatening emergency. Immediate communication with the family is more effective in this situation.

B. Explain that the healthcare team needs space to treat her husband: Clear, calm, and direct communication informs the family member of the critical need for room access and safety during resuscitation. This approach prioritizes patient care while showing respect and empathy for the spouse’s emotions, helping her understand the necessity of leaving temporarily.

C. Ask an administrative supervisor to assist the wife to the waiting area: Involving administration may escalate tension and delay urgent care. While sometimes necessary for compliance issues, this is not the first-line approach during an acute resuscitation.

D. Allow the wife to stay at the bedside with a healthcare team member: Allowing family presence can be supportive in some situations, but during active VF resuscitation, space and immediate access to the patient are critical. Safety and efficiency of the resuscitation take priority.

A. Complete a neurological assessment using the Glasgow Coma Scale. B. Collect specimens for serum electrolytes and digoxin levels. C. Bring the crash cart to the bedside for immediate accessibility. D. Obtain a prescription for digoxin immune fab IV.

Correct Answer is B

Explanation

Rationale:
A. Complete a neurological assessment using the Glasgow Coma Scale: While assessing neurological status is important, the client’s symptoms of nausea, vomiting, confusion, and blurred vision are classic signs of digoxin toxicity. Lab evaluation takes priority to confirm toxicity and guide treatment.

B. Collect specimens for serum electrolytes and digoxin levels: Digoxin toxicity is influenced by drug levels and electrolyte imbalances (especially potassium, magnesium, and calcium). Obtaining these labs allows the provider to confirm toxicity and determine appropriate management.

C. Bring the crash cart to the bedside for immediate accessibility: While the client is at risk for arrhythmias due to digoxin toxicity, immediate verification of digoxin levels and electrolytes is the first step before initiating emergency treatment.

D. Obtain a prescription for digoxin immune fab IV: Digoxin-specific antibody therapy is reserved for severe toxicity with life-threatening arrhythmias or hyperkalemia. Administering it without confirmation and lab assessment would be premature.

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A client with a femoral arterial sheath is admitted to the cardiac care unit (CCU) after a percutaneous transluminal coronary angioplasty (PTCA). Which intervention should the nurse provide during the first hour of postoperative care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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