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 ["1.5"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 30 mg
Available Concentration: 100 mg/5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (30 ÷ 100) × 5
Volume to administer = 0.3 × 5
Volume to administer = 1.5 mL
Correct Answer is A
Explanation
A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.
B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.
C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.
D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.
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