A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?
Elevate the head of the bed 45".
Keep the affected leg slightly flexed.
Keep the client NPO for 4 hr.
Have the client lie flat in bed.
The Correct Answer is D
Correct answer: D
A. Elevate the head of the bed 45": Do not elevate the head of the bed more than 15 degrees. Elevating the head of the bed can increase the risk of bleeding from the insertion site.
B. Keep the affected leg slightly flexed: The affected leg should be kept straight to prevent movement at the insertion site, which can cause bleeding
C. Keep the client NPO for 4 hr: There is typically no need to keep the client NPO for an extended period after a cardiac catheterization. However, individual protocols may vary, and the nurse should follow the specific instructions provided by the healthcare provider.
D. Have the client lie flat in bed: After a cardiac catheterization, it is important to keep the client lying flat to prevent bleeding or hematoma formation at the catheter insertion site. This position helps to maintain pressure on the insertion site, particularly if the catheter was inserted through the femoral artery.
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Related Questions
Correct Answer is D
Explanation
A. Dependent edema: Dependent edema is more commonly associated with right-sided heart failure. In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms such as cough and frothy sputum.
B. Jugular distention: Jugular distention is often associated with right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. It is less likely to be prominent in left-sided heart failure.
C. Nocturnal polyuria: Nocturnal polyuria (increased urination at night) is a common symptom of heart failure, but it is not specific to left-sided heart failure. It can be seen in both left- and right-sided heart failure.
D. Frothy sputum: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in the accumulation of fluid in the lungs. Frothy, pink-tinged sputum is a characteristic finding in left-sided heart failure and is often associated with pulmonary edema.
Correct Answer is D
Explanation
A. Restrict the client's fluid intake: There is typically no need to restrict fluid intake after a cardiac catheterization. Adequate hydration is important for preventing complications and promoting recovery.
B. Ambulate the client 1 hr following the procedure: While early ambulation is encouraged in many cases, the timing may vary based on the specific protocols of the healthcare provider. It is important to follow the healthcare provider's orders regarding post-catheterization ambulation.
C. Instruct the client to perform range-of-motion exercises to his lower extremities: Range-of-motion exercises are beneficial to prevent complications such as venous stasis and deep vein thrombosis. However, the specific exercises and timing may vary. It is important to follow the healthcare provider's instructions.
D. Perform neurovascular checks with vital signs: This is the correct answer. After a cardiac catheterization accessed through the femoral artery, it is crucial to monitor neurovascular status in the affected extremity. Assessing peripheral pulses, skin color, temperature, and capillary refill, along with monitoring vital signs, helps detect any signs of complications such as bleeding or vascular compromise.
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