A nurse is caring for a patient immediately following a cardiac catheterization with a femoral artery approach. Which action should the nurse take?

Remind the patient not to turn from side to side.

Keep the patient in a high-Fowler’s position for 6 hours.

Perform passive range-of-motion for the affected extremity.

Check pedal pulses every 15 minutes.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).

Early ambulation is generally encouraged to promote circulation and prevent blood clots.

Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.

Choice B rationale:

Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.

The patient's position should be based on their individual needs and comfort level.

In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.

Choice C rationale:

Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.

This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.

Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.

Choice D rationale:

Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.

This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.

If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.

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Correct Answer is B

Explanation

Choice A rationale:

While explaining the importance and rationale of the new policy can be helpful, it may not address the underlying reasons for the nurse's resistance.

If the nurse does not understand or agree with the rationale, they may still be resistant to change.

Additionally, simply providing information may not create an open and trusting environment where the nurse feels comfortable expressing their concerns.

Choice B rationale:

Encouraging the nurse to verbalize their concerns allows the nurse manager to understand the specific reasons for the resistance.

This can help to identify any misconceptions or concerns that can be addressed directly.

It also gives the nurse an opportunity to feel heard and understood, which can help to build trust and rapport. When nurses feel that their concerns are being taken seriously, they are more likely to be open to change.

Choice C rationale:

Threatening disciplinary action is likely to create resentment and further resistance. It may also damage the relationship between the nurse manager and the nurse.

This approach should only be used as a last resort, after other attempts to address the resistance have failed.

Choice D rationale:

Ignoring the resistance is not an effective strategy.

It is likely to lead to continued noncompliance with the new policy,

It may also send the message that the nurse manager does not care about the nurse's concerns.

Peer pressure can sometimes be helpful in facilitating change, but it should not be relied upon as the sole strategy.

A. A patient who has heart failure and is receiving diuretic therapy. B. A patient who has gastroenteritis and is receiving oral fluids. C. A patient who has end-stage kidney disease who will undergo dialysis. D. A patient who has NPO status since midnight for an endoscopy.

Correct Answer is D

Explanation

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

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