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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. "This test will help my provider adjust my warfarin dosages": aPTT is not typically used to monitor warfarin therapy. Instead, it is more commonly associated with monitoring heparin therapy.

B. "If my levels are too low, I am at an increased risk for bleeding": This statement is inaccurate. Low levels of clotting factors could lead to a prolonged aPTT, which might increase the risk of bleeding.

C. "It measures deficiencies in clotting factors."

Activated partial thromboplastin time (aPTT) is a laboratory test that evaluates the intrinsic pathway of the coagulation cascade. The aPTT measures the time it takes for a clot to form and reflects the activity of various clotting factors, including factors VIII, IX, XI, and XII. An elevated aPTT may indicate a deficiency or dysfunction of one or more clotting factors.

D. "I will need to skip breakfast until after the test is complete": There is no need for the client to skip breakfast before an aPTT test. The test is not affected by food intake.

A. "I will take my diuretic before sleep and drink fluids during the day. B. I plan to slow down if I am tired the day after exercising." C. "I will read food labels and limit my sodium to 4 grams per day." D. "I should use naproxen to manage discomfort."

Correct Answer is B

Explanation

Correct answer: B

A. "I will take my diuretic before sleep and drink fluids during the day": This statement is not correct. Diuretics are usually taken in the morning to avoid disrupting sleep with increased urination at night. Additionally, fluid intake is generally restricted in congestive heart failure to manage fluid balance.

B. "I plan to slow down if I am tired the day after exercising":This statement reflects an understanding of the need to manage activity levels and recognize the signs of overexertion, which is crucial for clients with congestive heart failure. Pacing activities and allowing for adequate rest can help prevent exacerbations of heart failure symptoms.

C. "I will read food labels and limit my sodium to 4 grams per day": This is incorrect. Limiting sodium intake is a key component of heart failure management. The recommended sodium intake for individuals with heart failure is often much lower than 4 grams per day, typically around 2 grams or less.

D. "I should use naproxen to manage discomfort": Using nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen can contribute to fluid retention and worsen heart failure symptoms. This statement is not indicative of effective teaching.

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A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

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