A nurse is caring for a 62-year-old client who underwent a cardiac catheterization via the right femoral artery 2 hours ago for the evaluation of ischemic heart disease. Which of the following nursing actions will reduce the client's risk for post-procedure complications? Select all that apply.
- Instructing the client to keep the right leg straight and immobilized.Answer
- BElevating the head of the bed to a 60-degree angle to promote client comfort.
- Palpating the bilateral pedal pulses and comparing the temperature of the lower extremities.Answer
- DDelegating the routine 15-minute vital sign checks and puncture site inspections to an unlicensed assistive personnel (UAP).
- EDocumenting a new onset of tachycardia and a narrowing pulse pressure as an expected response to procedural anxiety.
- Encouraging an increased intake of oral fluids unless contraindicated by the client's cardiopulmonary status.Answer
Answer
The correct actions include instructing the client to keep the right leg straight, assessing bilateral pedal pulses and limb temperature, and encouraging oral fluid intake.
To reduce risk potential after a femoral cardiac catheterization, the nurse must prevent bleeding by keeping the affected extremity straight, monitor for arterial occlusion via frequent bilateral neurovascular checks, and promote the excretion of nephrotoxic contrast media by encouraging fluid hydration.
Step-by-Step Solution
Key Concept
Post-Cardiac Catheterization Care and Complication Prevention