A nurse is caring for a patient immediately following a cardiac catheterization with a femoral artery approach. Which action should the nurse take?
Remind the patient not to turn from side to side.
Keep the patient in a high-Fowler’s position for 6 hours.
Perform passive range-of-motion for the affected extremity.
Check pedal pulses every 15 minutes.
The Correct Answer is D
Choice A rationale:
It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).
Early ambulation is generally encouraged to promote circulation and prevent blood clots.
Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.
Choice B rationale:
Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.
The patient's position should be based on their individual needs and comfort level.
In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.
Choice C rationale:
Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.
This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.
Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.
Choice D rationale:
Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.
This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.
If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:
Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.
Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.
Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.
Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.
Rationale for other choices:
B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.
C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.
D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.
Correct Answer is B
Explanation
Choice A rationale:
Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.
While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.
It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice B rationale:
Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).
It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.
This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.
Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.
Choice C rationale:
Naloxone is not effective in treating nausea.
In fact, it can actually worsen nausea in some patients.
This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.
Choice D rationale:
Naloxone is not effective in treating urinary retention.
Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.
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