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. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.
Correct Answer is C
Explanation
A. Offer the client several choices at mealtimes. Clients with delirium often experience confusion and difficulty processing information. Providing too many choices can increase anxiety and agitation. Instead, offering simple and limited options helps reduce cognitive overload.
B. Alternate daily caregivers. Consistency in caregivers is important for clients with delirium to minimize confusion and distress. Frequent changes in caregivers can contribute to disorientation and make it more difficult for the client to feel secure.
C. Remind the client of the day and time often. Delirium is characterized by fluctuating levels of consciousness and confusion. Frequent orientation to time, place, and situation helps reduce anxiety and supports cognitive function. Using clocks, calendars, and familiar objects in the environment can reinforce orientation.
D. Avoid discussing the client's fears. Clients with delirium may have distressing thoughts or fears that should be acknowledged and addressed. Providing reassurance and a calm, supportive environment can help alleviate anxiety and improve the client's well-being.
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