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Difficulty: EasyBasic Care and Comfort

An older adult client is recovering on a telemetry unit two hours after undergoing a left femoral cardiac catheterization. The client expresses mild back pain from prolonged bed rest and demonstrates new-onset confusion. Which of the following actions should the nurse include in the immediate care plan? Select all that apply.

  1. Offer the client a bedpan for elimination to avoid bending the affected left leg.Answer
  2. Guide the client through deep breathing and relaxation exercises to help manage back discomfort.Answer
  3. C
    Assign an unlicensed assistive personnel to inspect the left groin dressing for bleeding.
  4. D
    Roll the client onto their right side to alleviate the reported back pressure.
  5. E
    Apply soft bilateral wrist restraints immediately to prevent the client from pulling at the groin site.
  6. F
    Inform the family that sudden disorientation is a standard, age-related reaction to being hospitalized.

Answer

The correct actions are to offer the client a bedpan for elimination and to guide them through deep breathing and relaxation exercises.
Offering a bedpan allows the client to eliminate without getting out of bed or bending the affected leg, which perfectly aligns with the strict positioning requirements following a femoral procedure. Additionally, guiding the client through deep breathing exercises provides a safe, effective, non-pharmacological comfort measure to manage back pain when turning is strictly contraindicated.

Step-by-Step Solution

1
Identify the client's strict post-procedure positioning requirements.
Following a left femoral cardiac catheterization, the client must remain supine with the left leg completely straight to prevent severe bleeding at the arterial puncture site.
Maintaining vascular integrity is the highest priority.
2
Address the client's report of back pain.
Because the client cannot be rolled or repositioned to relieve pressure, alternative non-pharmacological comfort measures like deep breathing and relaxation must be utilized.
Basic comfort must be maintained without compromising the required therapeutic positioning.
3
Evaluate the new-onset confusion.
Sudden confusion is an acute clinical change requiring direct RN assessment. It cannot be dismissed as normal aging, cannot be managed immediately by applying restraints, and its assessment cannot be delegated.
Confusion in an older adult often points to hypoxia, stroke, or infection, necessitating a higher level of clinical judgment.

Key Concept

Basic care and comfort post-femoral catheterization requires maintaining a straight extremity to prevent bleeding. Comfort and elimination must be managed without altering this position. Furthermore, new-onset confusion in older adults requires acute nursing assessment and is never a normal age-related change.
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Basic Care and Comfort

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