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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea in some individuals. It is recommended to wait a while after eating before brushing teeth, or rinse the mouth with water.
B. Lying down after meals can worsen symptoms of nausea and reflux. Remaining upright or sitting up after meals may help alleviate symptoms.
C. Drinking large amounts of water with meals may exacerbate feelings of fullness and contribute to nausea. Sipping small amounts of fluids between meals is recommended.
D. Eating a dry carbohydrate, such as crackers or toast, before getting out of bed can help alleviate morning sickness by stabilizing blood sugar levels and absorbing stomach acid.
Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}
Explanation
A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here
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