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. Speaking directly into one of the client's ears may not effectively improve communication for someone with a hearing impairment, especially if the impairment is bilateral.

B. Rephrasing sentences the client does not understand can help improve comprehension by providing information in a different way.

C. Dropping voice volume at the end of sentences may make it difficult for the client to hear the end of the sentence, especially if they have a hearing impairment.

D. Exaggerating lip movements may not be helpful and can actually make lip-reading more difficult for some individuals.

A. "Wear an underwire bra between feedings." B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding."

Correct Answer is D

Explanation

A. "Wearing an underwire bra between feedings" can compress the breast tissue, potentially leading to milk stasis and increasing the risk of mastitis.

B. "Covering your breasts immediately after feedings" can trap moisture and warmth, creating an environment conducive to bacterial growth and increasing the risk of mastitis.

C. "Applying cold compresses to your breasts before feedings" may provide temporary relief for discomfort, but it is not a primary preventive measure for mastitis.

D. "Trying to have your baby empty your breasts with each feeding" helps ensure thorough milk removal, which can prevent milk stasis and decrease the risk of mastitis. This is the correct choice.

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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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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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