A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?
Assess the insertion site.
Keep the client NPO for 4 hr.
Keep the affected leg slightly flexed.
Elevate the head of the bed 45°.
The Correct Answer is A
A. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.
B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.
C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.
D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.
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Related Questions
Correct Answer is D
Explanation
A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.
B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.
C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.
D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.
Correct Answer is B
Explanation
A. Hamburger on a bun, banana: This choice is high in protein and potassium, which may not be suitable for someone with chronic renal disease, as excessive potassium intake can be harmful to individuals with impaired kidney function.
B. Carrots, green leafy vegetables, a pear: This choice is low in potassium and phosphorus, making it suitable for someone with chronic renal disease. Carrots and green leafy vegetables are generally lower in potassium, and a pear is a low-potassium fruit option.
C. Spaghetti with meat sauce, breadstick: This choice may be high in protein and sodium, depending on the sauce and breadstick ingredients, which may not be ideal for someone with chronic renal disease.
D. Cold cuts with bun, blueberries: Cold cuts can be high in sodium, and blueberries are moderately high in potassium, so this choice may not be appropriate for someone with chronic renal disease.
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