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Difficulty: MediumBasic Care and Comfort

An older adult client is transferred to the medical-surgical unit after a cardiac catheterization accessed via the right femoral artery. The client is on bed rest, has a history of osteoarthritis, and reports generalized back stiffness. Which of the following nursing actions should be included in the client's basic care and comfort plan? Select all that apply.

  1. Administer a gentle back massage to alleviate musculoskeletal stiffness while keeping the right leg straight.Answer
  2. B
    Elevate the head of the bed to 60 degrees to assist the client in drinking fluids comfortably.
  3. C
    Direct the unlicensed assistive personnel (UAP) to perform the initial post-procedure evaluation of the distal pedal pulses.
  4. Place a small, flat pillow under the client's head and neck to reduce cervical strain.Answer
  5. E
    Attribute the client's sudden onset of severe disorientation to expected age-related cognitive decline.

Answer

The nurse should administer a gentle back massage while keeping the right leg straight, and place a small, flat pillow under the client's head and neck.
Providing a back massage and using a small neck pillow safely address the client's osteoarthritis and generalized stiffness without compromising the required straight alignment of the affected leg. Maintaining a straight right leg and keeping the head of the bed at 30 degrees or lower is crucial to prevent arterial bleeding at the femoral access site.

Step-by-Step Solution

1
Analyze the client's specific post-procedure safety requirements.
Following a femoral cardiac catheterization, the affected extremity must remain completely straight (with the head of the bed flat or minimally elevated) to prevent bleeding and hematoma formation at the puncture site.
Flexing the hip joint increases pressure on the femoral artery access site.
2
Evaluate comfort measures for a client with osteoarthritis on strict bed rest.
A back massage and a small neck pillow provide musculoskeletal relief without violating the strict positioning requirements of the right leg.
Basic care and comfort must be balanced with post-procedural safety restrictions.
3
Assess the delegation and clinical judgment actions presented in the options.
Initial pulse evaluations cannot be delegated to UAPs, and acute cognitive changes must be investigated as complications rather than normal aging.
Adhering to scope of practice and recognizing acute pathological changes are critical components of safe nursing care.

Key Concept

Basic Care and Comfort during Post-Procedural Immobilization
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Topics

Basic Care and Comfort

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