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 D
Explanation
A. "Justice." Justice refers to fairness in the distribution of resources, treatment, and care. It involves ensuring that all clients receive equal and appropriate care based on their needs. While justice is an important ethical principle, it is not directly related to the nurse’s promise to walk with the client.
B. "Nonmaleficence." Nonmaleficence is the obligation to do no harm. This principle guides nurses in preventing injury, minimizing risks, and ensuring client safety. While supporting the client can help reduce anxiety, the nurse’s action primarily reflects a different ethical principle.
C. "Autonomy." Autonomy refers to respecting a client’s right to make their own decisions regarding their care. The nurse should encourage autonomy by allowing the client to choose whether to walk in the courtyard, but the act of making a promise to accompany them aligns more closely with a different ethical principle.
D. "Fidelity." Fidelity involves keeping promises and being truthful in professional relationships. By committing to walk with the client daily and following through on that promise, the nurse is demonstrating fidelity by building trust and maintaining professional integrity.
Correct Answer is D
Explanation
A. "Position the car seat at a 90° angle." Positioning the car seat at a 90° angle is not recommended. The car seat should be reclined at an angle of 30 to 45 degrees to ensure that the infant's head does not flop forward, which can obstruct the airway.
B. "Keep the airbag on if the car seat is in the front seat." Keeping the airbag on when a car seat is in the front seat is unsafe. It is recommended to place the car seat in the back seat, as the force of an airbag deploying can be harmful to a child in a car seat.
C. "Put a small cushion under the newborn's head for support." Placing a cushion under the newborn's head is not recommended, as it can interfere with the proper positioning of the car seat and compromise the safety of the infant. The car seat is designed to provide support without additional cushions.
D. "Place the shoulder harnesses at the level of the infant's shoulders." Placing the shoulder harnesses at the level of the infant's shoulders is the correct practice. The harnesses should be positioned snugly at or just above the shoulders for optimal safety, ensuring that the infant is securely restrained in the car seat.
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