A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?
Elevate the head of the bed 45".
Keep the affected leg slightly flexed.
Keep the client NPO for 4 hr.
Have the client lie flat in bed.
The Correct Answer is D
Correct answer: D
A. Elevate the head of the bed 45": Do not elevate the head of the bed more than 15 degrees. Elevating the head of the bed can increase the risk of bleeding from the insertion site.
B. Keep the affected leg slightly flexed: The affected leg should be kept straight to prevent movement at the insertion site, which can cause bleeding
C. Keep the client NPO for 4 hr: There is typically no need to keep the client NPO for an extended period after a cardiac catheterization. However, individual protocols may vary, and the nurse should follow the specific instructions provided by the healthcare provider.
D. Have the client lie flat in bed: After a cardiac catheterization, it is important to keep the client lying flat to prevent bleeding or hematoma formation at the catheter insertion site. This position helps to maintain pressure on the insertion site, particularly if the catheter was inserted through the femoral artery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A."I will follow a daily diet high in calories and protein": While maintaining adequate nutrition is important, emphasizing a diet high in calories may not be suitable. A balanced diet, including adequate protein, is recommended.
B."I will avoid getting a flu shot": Individuals with emphysema are at an increased risk of respiratory infections, including influenza. Getting a flu shot is generally recommended to reduce the risk of infection and complications.
C. "I will inhale slowly through pursed lips to help me breathe better."
This statement reflects a correct understanding of a beneficial breathing technique for individuals with emphysema. Inhaling slowly through pursed lips can help create back pressure in the airways, preventing them from collapsing and promoting better air exchange in the lungs. This technique can assist in managing shortness of breath and improving overall respiratory function.
D."I will lie on my stomach to practice abdominal breathing every day": While practicing abdominal breathing can be beneficial, lying on the stomach may not be the most practical or comfortable position for this purpose. The emphasis should be on proper breathing techniques, which can be done in various positions, including sitting or standing.
Correct Answer is A
Explanation
A. Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation followed by apnea. This respiratory pattern is often observed in clients with conditions affecting the central nervous system, such as brain injury or stroke.
B. Apneustic respirations: Apneustic respirations are characterized by prolonged, gasping inhalations followed by extremely short, ineffective exhalations. This pattern is associated with damage to the pons, a part of the brainstem.
C. Stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a partially obstructed airway. It is not related to the described alternating pattern of hyperventilation and apnea.
D. Kussmaul respirations: Kussmaul respirations are deep, rapid respirations often seen in metabolic acidosis. They are not characterized by the alternating pattern described in the scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today