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: A 12-lead ECG can reveal changes in the ST segment, T wave, and QRS complex, which are indicative of myocardial ischemia, injury, or infarction. It is the first line diagnostic test that needs to be recorded within 10 minutes after the first medical contact in cases of suspected acute coronary syndromes.
Choice B reason: While pain radiating to the left arm can be a symptom of MI, it is not a definitive diagnostic action. It is a common symptom but can also be associated with other conditions.
Choice C reason: Checking the client's blood pressure is important in the overall assessment of the client's cardiovascular status but does not specifically diagnose MI. Blood pressure can be normal, elevated, or decreased in the case of MI.
Choice D reason: Auscultating heart tones can provide information about the presence of murmurs, gallops, or rubs, but it is not a specific diagnostic action for MI. Heart sounds may be normal during an MI.
Correct Answer is ["A","B","D"]
Explanation
Title: Choice A reason: Beta-blocking agent Beta-blocking agents are often used in the management of cirrhosis of the liver. They are particularly useful in managing portal hypertension, a common complication of cirrhosis. Beta-blockers lower elevated portal pressure and protect against variceal hemorrhage, a serious complication of portal hypertension. Therefore, a beta-blocking agent may be ordered for a client with cirrhosis of the liver.
Title: Choice B reason: Diuretic Diuretics are commonly used in the management of fluid retention, a frequent complication in patients with cirrhosis. Fluid retention can lead to conditions such as ascites (abdominal fluid accumulation) and edema (swelling in the legs, feet, or ankles)2. Diuretics help to remove excess fluid from the body, thereby managing these symptoms. Therefore, a diuretic may be ordered for a client with cirrhosis of the liver.
Title: Choice C reason: Opioid analgesic While opioid analgesics are powerful pain relievers, they should be used with caution in patients with cirrhosis of the liver. Opioids can precipitate hepatic encephalopathy, a condition characterized by altered mental status and neuromuscular dysfunction, which is a serious complication of cirrhosis. Therefore, an opioid analgesic may not be the best choice for a client with cirrhosis of the liver.
Title: Choice D reason: Lactulose Lactulose is a non-absorbable sugar that is widely used in the treatment of hepatic encephalopathy, a common complication in patients with cirrhosis. It works by reducing the absorption of ammonia in the gut, thereby lowering blood ammonia levels and improving symptoms of hepatic encephalopathy. Therefore, lactulose may be ordered for a client with cirrhosis of the liver.
Title: Choice E reason: Sedative Sedatives should be used with caution in patients with cirrhosis of the liver. Like opioids, they can precipitate hepatic encephalopathy. Therefore, a sedative may not be the best choice for a client with cirrhosis of the liver.
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