A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
Instruct the client to perform range-of-motion exercises to his lower extremities.
Restrict the client's fluid intake.
Perform neurovascular checks with vital signs.
Ambulate the client 1 hr following the procedure.
The Correct Answer is C
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
d Ambulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.
Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).
Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).
d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.
Correct Answer is ["125 mL\/hr"]
Explanation
To calculate the infusion rate, the nurse should use the following formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
Plugging in the given values, the nurse should get:
Infusion rate (mL/hr) = 250 mL / 2 hr
Infusion rate (mL/hr) = 125 mL/hr
The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should set the IV pump to deliver 125 mL/hr.
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