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
Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and effectiveness of the medication.
Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.
Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.
Stopping taking the medication if side effects are troublesome is not advisable, as nitroglycerin oral, sustained-release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side effects, such as headache, dizziness, hypotension, or tachycardia.
Correct Answer is C
Explanation
- A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
- The other options are not correct because:
- History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood flow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood flow to the affected area.
- Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
- Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.
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