A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take?
Monitor the dorsalis pedis pulse every 15 min.
Place the client in Fowler's position.
Keep the client NPO for 24 hr.
Maintain strict bedrest for the first 12 hr.
The Correct Answer is A
A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.
B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.
C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.
D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.
B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.
C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.
D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.
Correct Answer is D
Explanation
A. BUN 22 mg/dL (10 to 20 mg/dL): A slightly elevated BUN indicates mild renal impairment or dehydration but does not typically require withholding enoxaparin. Monitoring renal function is important, but this value alone is not a contraindication for anticoagulation.
B. WBC count 15,000/mm3 (5,000 to 10,000/mm3): An elevated WBC suggests possible infection or inflammation. While it may warrant further assessment, it does not directly increase the risk of bleeding and is not a reason to withhold enoxaparin.
C. Urine specific gravity 1.04 (1.005 to 1.03): A high specific gravity may indicate dehydration but is not a contraindication for enoxaparin administration. The medication can be given with caution while monitoring renal function and fluid status.
D. Platelets 80,000/mm3 (150,000 to 400,000/mm3): Thrombocytopenia significantly increases the risk of bleeding while on enoxaparin, which is an anticoagulant. Withholding the dose and notifying the provider is essential to prevent hemorrhagic complications and ensure safe management of the client.
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