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 B
Explanation
A. "I will bathe my baby under a faucet of running water." Bathing a newborn under a running faucet increases the risk of accidental injury, sudden temperature changes, and loss of control while handling the baby. Instead, a gentle sponge bath or bathing in a small tub with controlled water temperature is recommended.
B. "I will wash my baby's face with a warm, wet washcloth without soap." This is an appropriate practice for newborn care. Using only warm water without soap helps prevent skin irritation, as a newborn’s skin is sensitive and prone to dryness. Special attention should be given to cleaning the eyes, nose, and mouth area gently.
C. "I will give my baby a bath every day." Daily bathing is not necessary for newborns and can lead to skin dryness and irritation. Instead, bathing two to three times per week is sufficient, with daily cleaning of the diaper area, face, and hands as needed.
D. "I will wash my baby's head using a moist towelette." While cleaning the baby’s head is important, a moist towelette is not the best method. The scalp should be gently washed with warm water and a mild baby shampoo to prevent buildup of oils and potential conditions like cradle cap.
Correct Answer is D,A,B,C
Explanation
D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.
A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.
B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.
C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.
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