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 B

Explanation

A. Delegating tasks to appropriate personnel is an important skill, but effective time management also involves personal task completion.

B. Completing activities for one client before moving to the next helps ensure tasks are not left incomplete and promotes organized workflow.

C. Focusing on objectives rather than just activities is a more comprehensive approach to time management, ensuring tasks align with goals.

D. Skipping break times can lead to burnout and decreased efficiency over time, rather than improving time management skills.

A. The gastric residual volume is 250 mL following 2 hr of infusion. B. The client is lying in a supine position. C. The infusion pump for administering continuous feeding is turned off. D. The enteral feeding bag and tubing are not dated.

Correct Answer is B

Explanation

A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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