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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).
A. The student needs to go to the hospital.
This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.
B. The nurse should obtain a second expiratory flow rate.
Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.
C. The student should use his quick-relief inhaler.
In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.
D. The student's peak flow is 50% to 80% of his best peak flow.
This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.
E. The student's asthma is not well controlled.
Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.
Correct Answer is B
Explanation
A. Myringotomy: Myringotomy is a procedure involving the insertion of tubes into the eardrum to treat conditions such as chronic ear infections. This procedure is not associated with a significant risk of deep-vein thrombosis.
B. Hip arthroplasty: Hip arthroplasty, or hip replacement surgery, is associated with an increased risk of deep-vein thrombosis due to factors such as immobility, surgical trauma, and alterations in blood flow. Prophylactic measures, such as anticoagulant medications and early ambulation, are often employed to reduce this risk.
C. Cataract extraction: Cataract extraction is a procedure to remove a cloudy lens from the eye. This surgery is not typically associated with a high risk of deep-vein thrombosis.
D. Laparoscopic appendectomy: Laparoscopic appendectomy, a minimally invasive procedure to remove the appendix, is generally associated with a lower risk of deep-vein thrombosis compared to major orthopedic surgeries like hip arthroplasty.
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