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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Your health care surrogate will make decisions on your behalf if you are unable." A health care surrogate, also known as a durable power of attorney for health care, is a person designated to make medical decisions when the client is unable to do so. This ensures that the client’s wishes are respected in situations where they cannot communicate or make informed choices.
B. "Once you have completed a living will, it cannot be changed." A living will can be revised or revoked at any time as long as the client is mentally competent. Changes may be necessary due to evolving personal beliefs, medical advancements, or changes in health status.
C. "You should appoint a family member as your health care surrogate." While a family member can be chosen, it is not a requirement. The client has the right to appoint anyone they trust to make medical decisions, including a close friend or legal representative, as long as they meet the legal criteria in their state or country.
D. "You will need an attorney to appoint a health care surrogate." An attorney is not required to appoint a health care surrogate. Most states provide standardized forms that can be completed and signed by the client in the presence of witnesses or a notary, depending on local legal requirements.
Correct Answer is B
Explanation
A. Completely undress the toddler. Toddlers may feel vulnerable when fully undressed. It is best to remove clothing gradually, assessing one area at a time, to promote comfort and reduce anxiety.
B. Allow the toddler to handle the equipment. Letting the toddler touch and explore medical equipment, such as a stethoscope or otoscope, helps reduce fear and increases cooperation during the examination. This approach fosters a sense of control and familiarity.
C. Thoroughly explain each procedure to the toddler. Toddlers have limited understanding and attention spans. Simple, short explanations and distraction techniques are more effective in easing anxiety than detailed explanations.
D. Start the examination with routine immunizations. Painful procedures, such as vaccinations, should be saved for the end of the visit to prevent distress and resistance that could interfere with the rest of the examination.
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