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.
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Related Questions
Correct Answer is C
Explanation
Title: Choice A reason: Liver enzymes Liver enzymes are proteins that speed up chemical reactions in your body. They include alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP). High levels of liver enzymes in the blood can indicate liver disease. However, rheumatic endocarditis is a heart condition, not a liver condition. Therefore, while liver enzymes are important for diagnosing liver conditions, they would not assist in confirming a diagnosis of rheumatic endocarditis.
Title: Choice B reason: Serum albumin Serum albumin is a type of protein that your liver and kidneys produce to help your body maintain fluid balance and function. Low or high albumin levels can indicate liver disease, kidney disease, or nutritional deficiency. However, rheumatic endocarditis is a heart condition, not a liver or kidney condition. Therefore, while serum albumin is important for diagnosing liver and kidney conditions, it would not assist in confirming a diagnosis of rheumatic endocarditis.
Title: Choice C reason: Throat culture A throat culture is a lab test used to find and identify germs in the back of your mouth that are making you sick. It can diagnose infections like strep throat, gonorrhea, thrush, diphtheria, and pertussis. Rheumatic endocarditis is often caused by a streptococcal infection, which can be identified through a throat culture. Therefore, a throat culture would assist in confirming a diagnosis of rheumatic endocarditis.
Title: Choice D reason: Arterial blood gases An arterial blood gas (ABG) test measures the levels of oxygen and carbon dioxide in your blood as well as the pH balance in your blood. It helps diagnose and monitor conditions that affect your respiratory, circulatory, and metabolic systems. However, rheumatic endocarditis is a heart condition that is often caused by a bacterial infection. Therefore, while an ABG test is important for diagnosing conditions that affect your respiratory, circulatory, and metabolic systems, it would not assist in confirming a diagnosis of rheumatic endocarditis.
Correct Answer is A
Explanation
Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.
Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.
Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.
Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.
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