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. "Sit on the edge of the bed while I tap your knee." The patellar reflex, also known as the knee-jerk reflex, is tested by tapping the patellar tendon while the client’s leg dangles. This does not assess the Babinski reflex, which involves stroking the sole of the foot.
B. "Lie down and I will stroke the bottom of your foot." The Babinski reflex is tested by stroking the lateral aspect of the sole from heel to toe. A normal response in adults is toe flexion, while dorsiflexion of the great toe with fanning of the others is abnormal and indicates neurological dysfunction.
C. "Place your foot in my hand and I will tap the back of your heel." This describes testing for the Achilles tendon reflex, which assesses the function of the S1 spinal nerve. The Babinski reflex requires a stroking motion along the foot’s sole rather than tapping the heel.
D. "Relax your arm across your chest and I will test your elbow extension." This describes testing the triceps reflex, which assesses the function of the C6-C7 nerve roots. The Babinski reflex is specific to neurological assessment of the lower extremities.
Correct Answer is A
Explanation
A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.
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