A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
Instruct the client to perform range-of-motion exercises to his lower extremities.
Restrict the client's fluid intake.
Perform neurovascular checks with vital signs.
Ambulate the client 1 hr following the procedure.
The Correct Answer is C
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
d Ambulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Correct Answer is B
Explanation
Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.
a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause fluid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.
c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause fluid retention and increase the workload of the heart.
d. "I will take my diuretic before sleep and drink fluids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can affect the quality of life and cardiac function. The
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