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 A
Explanation
A.
A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.
B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.
C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.
D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.
Correct Answer is C
Explanation
A. Alendronate should be taken on an empty stomach, preferably in the morning, and the client should wait at least 30 minutes before eating or drinking anything other than water.
B. Alendronate should be taken in the morning, not at bedtime, to reduce the risk of esophageal irritation and ensure proper absorption.
C. Taking alendronate with 8 ounces of water helps facilitate proper absorption and reduces the risk of esophageal irritation.
D. Increasing caffeine intake while taking alendronate is not recommended, as caffeine can interfere with calcium absorption and potentially worsen osteoporosis.
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