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Difficulty: HardBasic Care and Comfort

A practical nurse is providing basic care and comfort measures for a client who had a cardiac catheterization via the right femoral artery 2 hours ago. The client is on strict bed rest and reports mild lower back ache. Which of the following actions should the nurse include in the client's care? Select all that apply.

  1. Place a small, rolled towel under the lumbar region of the client's back.Answer
  2. B
    Elevate the head of the bed to 45 degrees to facilitate swallowing while the client eats.
  3. Use a low-profile fracture pan for elimination to minimize pelvic and leg movement.Answer
  4. D
    Instruct the client to periodically flex the right knee to relieve joint pressure.
  5. Offer oral fluids frequently by keeping a water pitcher within the client's reach.Answer
  6. F
    Apply a warm heating pad to the right groin insertion site to soothe procedural pain.

Answer

The correct actions are to place a rolled towel under the lumbar region, use a low-profile fracture pan for elimination, and offer oral fluids frequently.
After a femoral cardiac catheterization, the affected leg must remain straight and the head of the bed elevated no more than 30 degrees to prevent hemorrhage. Placing a small rolled towel under the lumbar region effectively relieves lower back ache without compromising this required positioning. Using a low-profile fracture pan allows for safe elimination while keeping the right leg straight and minimizing pelvic movement. Encouraging oral fluids is a vital basic care measure to excrete the contrast medium used during the procedure and maintain hydration.

Step-by-Step Solution

1
Identify the critical safety constraints for a post-femoral cardiac catheterization client.
The client must remain on strict bed rest with the affected (right) leg completely straight, and the head of the bed must not be elevated more than 30 degrees to prevent arterial bleeding.
Maintaining hemostasis at the femoral puncture site is the highest priority.
2
Evaluate the comfort and elimination options against the positioning constraints.
Providing a small lumbar roll and using a fracture pan allow the nurse to manage the client's back pain and elimination needs without flexing the hip or lifting the pelvis excessively.
Basic care must be adapted to fit strict procedural precautions.
3
Assess the remaining basic care interventions for safety and efficacy.
Offering oral fluids is safe and necessary to excrete contrast dye. Conversely, flexing the right knee, elevating the head to 45 degrees, or applying heat to the groin directly contradict safety protocols and risk hemorrhage.
Interventions that increase intra-abdominal pressure, bend the hip/knee, or cause vasodilation must be avoided.

Key Concept

Post-Procedure Basic Care and Positioning Precautions
Estimated Time:1m 30s
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Topics

Basic Care and Comfort

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