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 C
Explanation
A. Give 2 rescue breaths: In cardiac arrest due to V.Fib, the priority is circulation. High-quality chest compressions are initiated immediately to maintain perfusion until defibrillation can be performed. Rescue breaths are not the first step.
B. Start chest compressions: V.Fib is a lethal rhythm with no effective cardiac output. Immediate chest compressions are essential to circulate oxygenated blood to vital organs while preparing for defibrillation. This is the first action in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS).
C. Assess the client: While assessment is important, in the context of a witnessed rhythm strip showing V.Fib and an alarm, the nurse should assume cardiac arrest and act immediately. Delaying compressions to reassess wastes critical seconds.
D. Call a code blue/call 911: This is necessary, but it comes after starting chest compressions. The priority is to begin CPR without delay, then activate emergency response and prepare for defibrillation.
Correct Answer is ["A","B","D"]
Explanation
A. Bronchospasm: Non-selective beta-blockers inhibit beta-2 receptors located in the bronchial smooth muscle, leading to unintended constriction of the airways. This physiological response significantly increases airway resistance and can trigger acute respiratory distress in patients with underlying asthma or COPD. Clinicians must exercise extreme caution when prescribing these agents to individuals with reactive airway diseases.
B. Bradycardia: Beta-adrenoceptor antagonists decrease the firing rate of the sinoatrial node and slow conduction through the atrioventricular node. This negative chronotropic effect results in a reduced heart rate, which is a primary pharmacological action of the drug class. Excessive blockade can lead to symptomatic bradycardia, requiring a dose adjustment or discontinuation to maintain adequate cardiac output.
C. Hyperglycemia: Beta-blockers do not typically cause an elevation in blood glucose levels as a primary adverse effect. Instead, they are known to mask the sympathetic symptoms of hypoglycemia, such as tachycardia and tremors, which can be dangerous for diabetic patients. They may also slightly impair insulin release, but they are not categorized as hyper-glycemic agents.
D. Fatigue: The reduction in cardiac output and the blockade of peripheral beta-receptors often lead to a profound sense of lethargy or exercise intolerance. Patients frequently report feeling tired because the heart cannot increase its rate sufficiently to meet increased metabolic demands during physical activity. This is one of the most common reasons for patient non-compliance with beta-blocker therapy.
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