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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Aplastic anemia results in an inability to absorb vitamin B12: This statement is incorrect. Aplastic anemia is not related to the absorption of vitamin B12. It primarily involves a decrease in the production of blood cells by the bone marrow.

B. Aplastic anemia results from decreased bone marrow production of RBCs: This is the correct information. Aplastic anemia is a condition characterized by the failure of the bone marrow to produce an adequate number of blood cells, including red blood cells (RBCs), white blood cells (WBCs), and platelets.

C. Aplastic anemia results in an increased rate of RBC destruction: This statement is incorrect. Aplastic anemia is not associated with an increased rate of RBC destruction. Instead, it is characterized by a reduction in the number of blood cells produced by the bone marrow.

D. Aplastic anemia is associated with a decreased intake of iron: This statement is incorrect. Aplastic anemia is not related to a decreased intake of iron. It is primarily a disorder of bone marrow function leading to insufficient production of blood cells.

A. Tissue integrity B. Pain severity C. Airway patency D. Wound drainage

Correct Answer is C

Explanation

A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.

B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.

C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.

D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.

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A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

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