A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?
Apply a warm pack to the client's puncture site.
Monitor for bleeding at the catheter site.
Replace the client's pressure dressing in 2 hr.
Encourage the client to ambulate in 1 hr.
The Correct Answer is B
A. Apply a warm pack to the client's puncture site. Applying a warm pack to the puncture site is not appropriate immediately following cerebral angiography. Cold compresses are generally recommended initially to reduce swelling and discomfort, while warmth may be used later as advised by the healthcare provider.
B. Monitor for bleeding at the catheter site. Monitoring for bleeding at the catheter site is a critical action after cerebral angiography. The nurse should assess the site frequently for signs of hematoma or excessive bleeding, which can indicate complications from the procedure.
C. Replace the client's pressure dressing in 2 hr. The pressure dressing should not be replaced without specific orders from the healthcare provider. The nurse should assess the dressing for any signs of bleeding or drainage and follow the protocol for dressing changes as indicated.
D. Encourage the client to ambulate in 1 hr. Early ambulation may not be safe immediately after cerebral angiography, especially if the client has undergone a procedure involving sedation or if there is a risk of complications. The nurse should follow the provider's orders regarding activity restrictions and assess the client's readiness for ambulation based on their condition and vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain written consent by the client for the placement of the restraints. It is not typically required to obtain written consent from the client for the use of restraints. However, consent may be necessary for treatment in general, depending on the facility's policies and state laws. Restraints are usually applied to ensure safety and must be justified based on the client's behavior.
B. Release the client's restraints every 4 hr. Restraints should be released more frequently, typically every 1 to 2 hours, to assess the client's safety and physical condition and to allow for movement, hydration, and toileting as appropriate.
C. Document the client's behavior leading to the initiation of the restraints. Documenting the client's behavior that necessitated the use of restraints is crucial for legal and ethical reasons. This documentation provides a clear rationale for the use of restraints and helps ensure compliance with facility policies and regulations.
D. Check the client's status every hour. The client's status should be checked more frequently than every hour. Regular monitoring is essential to ensure the client's safety, comfort, and physical well-being while in restraints. The nurse should assess the client every 15 to 30 minutes based on facility protocols.
Correct Answer is D
Explanation
A. "You should avoid exercising for the next 6 weeks." Exercise is encouraged after a total hip arthroplasty to promote circulation, prevent complications such as deep vein thrombosis, and strengthen the muscles supporting the hip joint. However, high-impact activities should be avoided until cleared by the healthcare provider.
B. "You should avoid putting a pillow between your legs when in bed." Placing a pillow between the legs, especially while sleeping, helps maintain proper hip alignment and prevents excessive internal rotation or adduction, reducing the risk of dislocation.
C. "You should avoid lying on your right side." Lying on the operative side is not necessarily contraindicated, but it should be done with caution and with proper support. Clients are usually advised to lie on their non-operative side with a pillow between their legs for alignment.
D. "You should avoid crossing your legs for 3 months." Crossing the legs can cause hip adduction and internal rotation, increasing the risk of dislocation of the prosthetic joint. Clients are typically instructed to avoid crossing their legs for at least 3 months or until cleared by their provider.
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