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 A
Explanation
A. Red-colored urine: Rifampin, when taken orally or intravenously, can cause red discoloration of bodily fluids, including urine, sweat, saliva, and tears. This is a common and harmless side effect of the medication. Clients should be informed about this potential discoloration to avoid unnecessary concern.
B. Black-colored stools: Black-colored stools are not an expected side effect of rifampin.
C. Staining of teeth: While rifampin can cause staining of contact lenses, it is not associated with tooth discoloration.
D. Constipation: Constipation is not a common side effect of rifampin. Gastrointestinal side effects may include nausea, vomiting, and abdominal pain.
Correct Answer is A
Explanation
A. Cabbage: This is the correct answer. Cabbage is a food high in vitamin K, which can antagonize the effects of warfarin. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-rich foods, such as cabbage, can affect the stability of the client's international normalized ratio (INR).
B. Green beans: Green beans are not particularly high in vitamin K, and their consumption is not usually restricted for clients taking warfarin.
C. White beans: White beans are not particularly high in vitamin K, and their consumption is not usually restricted for clients taking warfarin.
D. Cantaloupe: Cantaloupe is not high in vitamin K, and its consumption is not usually restricted for clients taking warfarin.
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