The nurse is caring for a patient who has just returned from a cardiac catheterization through the femoral artery. The nurse knows that what three interventions are important to add to the patient's plan of care? (Select all that apply.)
Maintain pressure over the insertion site
Assist with amputation 2 hours after recovery
Place the client in semi-Fowler's position
Assess pedal pulses bilaterally
Monitor color and warmth of the left leg frequently
Correct Answer : A,D,E
A. Maintain pressure over the insertion site: The femoral artery is a high-pressure vessel, and the puncture site is at significant risk for hematoma or hemorrhage. Applying a pressure dressing or sandbag helps ensure hemostasis during the initial recovery period. Monitoring the site for bleeding is a critical nursing priority to prevent hypovolemic complications.
B. Assist with amputation 2 hours after recovery: Amputation is not a standard or expected outcome of a cardiac catheterization procedure. This intervention would only be considered in the case of extreme, irreversible limb ischemia, which is a rare and severe complication. Nursing care focuses on preserving the limb through vigilant neurovascular assessment.
C. Place the client in semi-Fowler's position: Following a femoral artery catheterization, the patient must remain supine with the affected leg kept straight for several hours. Elevating the head of the bed to semi-Fowler's position increases intra-abdominal pressure and the risk of bleeding at the groin site. Hip flexion is strictly contraindicated until the artery has sufficiently healed.
D. Assess pedal pulses bilaterally: Frequent assessment of distal pulses is necessary to ensure that the catheterization did not cause an arterial occlusion or thrombosis. Comparing the pulses in both feet allows the nurse to detect subtle changes in perfusion to the affected extremity. Weak or absent pulses require immediate notification of the surgical team.
E. Monitor color and warmth of the left leg frequently: Skin temperature and color are essential indicators of arterial blood flow and tissue oxygenation. A cold, pale, or cyanotic limb suggests compromised circulation distal to the femoral insertion site. These neurovascular checks are vital for early detection of vascular complications following the invasive procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Call the cardiologist: Contacting the specialist is necessary for definitive management but is not the most immediate nursing action. Delays in providing basic physiological support while waiting for a physician's response can lead to further myocardial damage. Initial stabilization must occur before coordinating the next level of specialized care.
B. Administer oxygen: Myocardial infarction involves a critical mismatch between oxygen supply and demand in the cardiac tissue. Providing supplemental oxygen increases the concentration of oxygen in the blood to help salvage ischemic myocardium and relieve dyspnea. This is a primary intervention to reduce the severity of the infarct and stabilize the patient.
C. Obtain vital signs: While baseline data is important for monitoring, the patient's immediate report of shortness of breath indicates an acute respiratory and circulatory crisis. Taking blood pressure and temperature does not actively treat the underlying hypoxia or chest pain. Interventions to improve oxygenation should take precedence over data collection during active ischemia.
D. Place the client in a supine position: Lying flat increases venous return and the workload of the heart, which can worsen both chest pain and shortness of breath. Patients in respiratory distress should be placed in a high-Fowler's position to maximize lung expansion and decrease cardiac strain. A supine position is physiologically detrimental during an acute coronary event.
Correct Answer is A
Explanation
A. IV fluid bolus of normal saline at 250 ml/hour: Administering a fluid bolus would be detrimental to a client already showing signs of volume overload, such as JVD and peripheral edema. This intervention would exacerbate the heart failure and worsen the client's respiratory distress. Fluid restriction is more likely indicated in this clinical scenario.
B. Furosemide and a calcium channel blocker: Furosemide will address the systemic edema and JVD by promoting diuresis and reducing fluid volume. A calcium channel blocker, such as diltiazem, is standard for rate control in atrial fibrillation to slow the ventricular response. This combination treats both the symptomatic fluid overload and the underlying arrhythmia.
C. Pantoprazole and digoxin: While digoxin can be used for rate control, pantoprazole is a proton pump inhibitor for gastric acid and does not address the client's primary cardiac issues. Digoxin alone would not treat the significant peripheral edema or JVD noted in the assessment. The primary goal is diuresis and rapid rate stabilization.
D. IV potassium and antibiotics: Antibiotics are used for bacterial infections, which are not suggested by the clear lung sounds and lack of fever. Potassium is only replaced if a deficit is confirmed via laboratory testing. These medications do not address the acute needs of a client in heart failure with a rapid heart rate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
