A nurse is planning care for a client who has undergone cardiac catheterization through the 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.
Ambulate the client 1 hour following the procedure.
Restrict the client's fluid intake.
Assess the color, temperature, and pulse in the affected extremity.
The Correct Answer is D
Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.
Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².
Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.
Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.
Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.
Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.
Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.
Correct Answer is A
Explanation
Choice A reason:Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution or harm the patient.
Choice B reason: The statement about the catheter becoming infected despite sterile precautions is accurate and reflects an understanding of the risks associated with peritoneal dialysis.
Choice C reason:Expecting the volume of the output solution to be greater than the input solution is incorrect; typically, the volumes should be equal to ensure proper fluid removal.
Choice D reason: The fluid from the abdomen being clear or slightly yellow is a normal finding and does not indicate a need for further teaching.
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