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Difficulty: HardBasic Care and Comfort

A 65-year-old client is admitted to the progressive care unit 2 hours after a cardiac catheterization utilizing the right femoral artery approach. The provider prescribes strict supine bed rest with the affected extremity kept straight for 6 hours. The client reports a severe backache, feels hungry, and states an urgent need to void. Which nursing actions are appropriate to address the client's basic care and comfort needs? Select all that apply.

  1. Slide a thin, rolled blanket under the lumbar region of the spineAnswer
  2. Utilize a fracture bedpan for urinary elimination while ensuring the right leg remains fully extendedAnswer
  3. C
    Place the client in a high Fowler's position temporarily to facilitate safe swallowing during a meal
  4. D
    Direct the patient care technician to assess the bilateral pedal pulses while providing perineal hygiene
  5. E
    Instruct the client to actively bend both knees to alleviate muscle tension in the lower back
  6. Apply a heel-suspension boot to the right lower extremity while keeping the leg in neutral alignmentAnswer

Answer

The correct interventions are providing a lumbar roll for comfort, using a fracture bedpan for elimination, and applying a heel-suspension boot to protect skin integrity.
The correct interventions successfully balance the client's fundamental needs for comfort, elimination, and skin protection with the strict physiological requirement to keep the right hip straight. Using a lumbar roll, a fracture bedpan, and a heel protector achieve these basic care goals without compromising the vascular puncture site.

Step-by-Step Solution

1
Analyze the client's clinical constraints
The client has a right femoral arterial puncture requiring strict flat bed rest and right leg immobilization.
Establishing physical limitations is necessary before implementing basic care interventions.
2
Evaluate comfort interventions for the reported backache
A lumbar roll is safe and effective; instructing the client to bend their knees is contraindicated due to required hip flexion.
Back pain is common during flat bed rest, but interventions must not alter the required straight alignment of the affected leg.
3
Evaluate elimination interventions
Using a fracture bedpan is appropriate because it requires minimal lifting and prevents hip flexion.
The client needs to void, but mobilizing to a commode or using a standard bedpan threatens the puncture site.
4
Evaluate positioning for nutrition
Sitting the client upright (high Fowler's) is strictly contraindicated.
Hip flexion above 15-30 degrees (depending on specific protocol) risks dislodging the arterial clot and causing hemorrhage.
5
Evaluate delegation and hygiene tasks
Delegating the assessment of pedal pulses is inappropriate.
Unlicensed personnel can perform the hygiene, but the RN must conduct all vascular assessments.
6
Evaluate skin integrity interventions
Applying a heel-suspension boot is a correct proactive measure.
Strict immobility rapidly increases the risk of heel breakdown; the boot provides protection while keeping the leg straight.

Key Concept

Providing fundamental care (elimination, comfort, skin integrity) while adhering to strict procedural immobility constraints.
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Topics

Basic Care and Comfort

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