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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:
Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.
Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.
Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.
Blood or secretions in the airway: These can obstruct the airway and cause stridor.
It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:
Oxygen therapy: This can help to improve the patient's breathing.
Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.
Correct Answer is A
Explanation
Choice A rationale:
Confidentiality: Patient information stored within the facility's computer system is highly confidential and protected by various laws and regulations, such as HIPAA (Health Insurance Portability and Accountability Act). Sharing a password with anyone, even trusted colleagues, could potentially compromise patient privacy and lead to unauthorized access or breaches of sensitive data. Nurses are ethically and legally obligated to safeguard patient confidentiality and uphold the highest standards of privacy protection.
Accountability: Each nurse is held individually accountable for any actions taken under their unique login credentials. Sharing a password blurs the lines of responsibility and makes it difficult to trace actions back to the specific individual who performed them. This can create accountability issues and impede investigations in cases of errors, misconduct, or security breaches.
Security Best Practices: Password sharing is universally discouraged by cybersecurity experts as it significantly weakens system security. Strong passwords, kept confidential and changed regularly, are essential for protecting sensitive information from unauthorized access, malware, and potential cyberattacks.
Facility Policies: Most healthcare facilities have strict policies prohibiting password sharing to maintain compliance with regulations and safeguard patient privacy. Violating these policies could lead to disciplinary action, including termination of employment.
Choice B rationale:
While a nurse manager may have a legitimate need to access patient information in certain situations, sharing a password is not the appropriate method for granting such access. Facilities typically have designated procedures for authorized individuals to obtain temporary or secondary login credentials, ensuring accountability and adherence to security protocols.
Choice C rationale:
Unit clerks, while often responsible for administrative tasks within a unit, do not have a clinical role that necessitates access to patient information through the nurse's password. Sharing a password with a unit clerk could lead to unauthorized access and potential privacy violations.
Choice D rationale:
The facility's information system representative is responsible for maintaining the technical infrastructure of the computer system, but they do not require access to patient information through individual nurse passwords. They have their own authorized means of accessing the system for troubleshooting and maintenance purposes.
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