A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Monitoring the insertion site for infection

Checking for orthostatic hypotension

Forcing fluids

Immobilizing the affected extremity

None

Answer and Explanation

The Correct Answer is D

A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.

B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.

C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.

D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.

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Correct Answer is A

Explanation

A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.

B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.

C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.

D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.

A. Auscultate the client's left arm for a bruit every 4 hours. B. Compare blood pressure in both arms every 2 hours. C. Instruct the client to keep the left arm in a dependent position. D. Encourage the client to restrict movement of the left arm.

Correct Answer is A

Explanation

A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.

B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.

C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.

D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.

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A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

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