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 A
Explanation
A. Fatigue: Hypokalemia (low potassium levels) can lead to fatigue and weakness. Potassium is essential for proper muscle and nerve function, and a deficiency can result in muscle weakness and decreased energy levels.
B. Pitting edema: Pitting edema is more commonly associated with fluid retention, which can occur in heart failure. Hypokalemia is not typically a direct cause of pitting edema.
C. Dyspnea: Dyspnea (shortness of breath) is a symptom commonly associated with heart failure, and while potassium imbalance can affect cardiac function, it is not a specific manifestation of hypokalemia.
D. Oliguria: Oliguria (decreased urine output) is not a typical manifestation of hypokalemia. However, it can be associated with heart failure and other renal conditions.
Correct Answer is D
Explanation
A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
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