A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

Apply a warm pack to the client's puncture site.

Monitor for bleeding at the catheter site.

Replace the client's pressure dressing in 2 hr.

Encourage the client to ambulate in 1 hr.

Answer and Explanation

The Correct Answer is B

A. Apply a warm pack to the client's puncture site. Applying a warm pack to the puncture site is not appropriate immediately following cerebral angiography. Cold compresses are generally recommended initially to reduce swelling and discomfort, while warmth may be used later as advised by the healthcare provider.
B. Monitor for bleeding at the catheter site. Monitoring for bleeding at the catheter site is a critical action after cerebral angiography. The nurse should assess the site frequently for signs of hematoma or excessive bleeding, which can indicate complications from the procedure.
C. Replace the client's pressure dressing in 2 hr. The pressure dressing should not be replaced without specific orders from the healthcare provider. The nurse should assess the dressing for any signs of bleeding or drainage and follow the protocol for dressing changes as indicated.
D. Encourage the client to ambulate in 1 hr. Early ambulation may not be safe immediately after cerebral angiography, especially if the client has undergone a procedure involving sedation or if there is a risk of complications. The nurse should follow the provider's orders regarding activity restrictions and assess the client's readiness for ambulation based on their condition and vital signs.

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Correct Answer is D

Explanation

A. Apply water-soluble lubricant to the site. Lubricants are not necessary for gastrostomy tube site care. Instead, the nurse should keep the area clean and dry to prevent irritation and infection. Applying lubricant could increase moisture, potentially leading to skin breakdown or fungal infections.
B. Attach an extension tube to the site's opening prior to use. Extension tubes are only needed for certain types of gastrostomy devices, such as low-profile buttons, and should be attached only when feeding or administering medications. Continuous attachment is unnecessary and may increase the risk of dislodgment or contamination.
C. Tape the tube to the child's cheek. Taping a gastrostomy tube to the cheek is inappropriate, as it does not provide adequate stabilization and may cause discomfort. This technique is more commonly used for securing nasogastric tubes rather than gastrostomy tubes.
D. Secure the tubing to the child's abdomen. Properly securing the gastrostomy tube to the abdomen helps prevent accidental dislodgment, irritation, and skin breakdown. The tube should be secured with tape or a securement device while allowing slight movement to reduce tension on the insertion site.

A. Trousseau's sign B. Irregular heart rate C. Hyperactive reflexes D. Dry mucous membranes

Correct Answer is B

Explanation

A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.

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A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

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