A nurse is planning care for a client who has undergone cardiac catheterization through the 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.
Ambulate the client 1 hour following the procedure.
Restrict the client's fluid intake.
Assess the color, temperature, and pulse in the affected extremity.
The Correct Answer is D
Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.
Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².
Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.
Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Heparin and warfarin do not work together to dissolve clots. Heparin acts quickly to prevent further clotting, while warfarin is used for long-term anticoagulation.
Choice B reason: Warfarin's onset of action is slow, requiring several days to reach therapeutic levels. During this time, heparin is used to provide immediate anticoagulation to prevent new clot formation or the growth of existing clots.
Choice C reason: IV heparin does not increase the effects of warfarin. They are used concurrently because of the delay in warfarin's onset of action.
Choice D reason: It is not appropriate to discontinue heparin immediately after starting warfarin due to the delay in warfarin reaching therapeutic levels. The overlap is necessary to ensure continuous anticoagulation.
Correct Answer is ["A","B","C"]
Explanation
Tachycardia, or a rapid heartbeat, is a common response to the pain and stress associated with stomach perforation. The body’s sympathetic nervous system is activated in response to the pain and the potential shock state due to internal bleeding or infection, leading to an increased heart rate. Tachycardia is also a compensatory mechanism to maintain adequate blood flow and oxygen delivery to vital organs in the setting of decreased blood volume. A stomach perforation due to a peptic ulcer is a serious medical condition where an ulcer has led to a hole in the stomach lining. This can lead to the contents of the stomach spilling into the abdominal cavity, causing peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity).
Choice B: Rebound tenderness
Rebound tenderness is a clinical sign that indicates irritation of the peritoneum. When pressure is applied to the abdomen and then quickly released, the sudden movement of the peritoneal layers against each other produces sharp, rebound pain. This is a classic sign of peritonitis, which can occur with stomach perforation as gastric contents irritate the peritoneum. When assessing a client with a suspected stomach perforation due to a peptic ulcer, a nurse should expect to find signs of tachycardia, rebound tenderness, and a rigid abdomen. These findings are indicative of the body’s response to the acute abdominal condition and peritoneal irritation. It is crucial to recognize these signs promptly as stomach perforation is a medical emergency requiring immediate intervention.
Choice C: Rigid abdomen
A rigid abdomen is indicative of involuntary guarding, a reflex contraction of the abdominal muscles to protect inflamed organs within the abdomen. This rigidity is a sign of peritoneal irritation and is often present in cases of stomach perforation. The rigidity helps to immobilize the area, which may reduce pain but also serves as a clinical indicator of serious intra-abdominal pathology.
Choice D: Elevated blood pressure
Elevated blood pressure is not typically a direct result of stomach perforation. In fact, blood pressure may initially be normal or even low, depending on the body’s response to internal bleeding and the potential development of shock. However, pain and anxiety can cause a transient increase in blood pressure, but it is not a primary diagnostic criterion for stomach perforation.
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