A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

Monitor the client's vital signs once every hour.

Restrict the client's fluid intake.

Elevate the head of the client's bed to a 45° angle.

Instruct the client not to bend the affected leg.

Answer and Explanation

The Correct Answer is D

A. Vital signs should be monitored more frequently immediately after cardiac catheterization to detect any complications early, such as bleeding or changes in hemodynamic status.

B. Fluid intake is not typically restricted unless specified by the provider due to specific medical conditions or complications.

C. The head of the bed should generally be kept flat or at a minimal angle (15-30 degrees) to reduce the risk of bleeding or hematoma formation at the catheterization site.

D. Instructing the client not to bend the affected leg helps prevent complications such as bleeding from the femoral artery or formation of a hematom

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Correct Answer is A

Explanation

A. Increasing the elevation of the affected extremity helps to relieve pressure and maintain proper alignment of the fracture. This action ensures that the traction remains effective and that the weights are properly suspended.

B. Removing weights can compromise the effectiveness of the traction and should only be done under specific orders from a healthcare provider.

C. Tying knots in the ropes can alter the alignment and effectiveness of the traction. Proper adjustment should be made by healthcare professionals according to protocol.

D. Pulling the client up in bed does not address the issue of the weights resting on the floor and may cause further complications.

A. Negative sputum cultures for acid-fast bacillus B. Positive Quantiferon-TB Gold test (negative) C. Client no longer coughing up blood-tinged sputum D. Mantoux skin test revealing an induration of less than 1 mm

Correct Answer is A

Explanation

A. Negative sputum cultures for acid-fast bacillus indicate that the Mycobacterium tuberculosis bacteria are no longer present in the sputum, meaning the client is no longer infectious.

B. A positive Quantiferon-TB Gold test indicates TB infection but does not determine infectiousness.

C. The absence of blood-tinged sputum does not confirm that the client is no longer infectious.

D. The Mantoux skin test does not determine the infectious status; it only indicates TB infection.

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