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Difficulty: HardBasic Care and Comfort

A client who underwent a cardiac catheterization via the right femoral artery is currently on strict bed rest. The nurse observes that the client has been incontinent of urine and needs immediate perineal care and a linen change. Which of the following is the most appropriate action for the nurse to take?

  1. Assist the client to turn onto the left side while maintaining the right leg in a straight, neutral position.Answer
  2. B
    Raise the upper half of the bed to a 60-degree angle to provide better visibility and access for perineal cleaning.
  3. C
    Instruct the assistive personnel to independently turn the client and change the linens while the nurse prepares medications.
  4. D
    Apply soft bilateral wrist restraints before beginning the linen change to protect the femoral insertion site from contamination.

Answer

The most appropriate action is to assist the client to turn onto the left side while maintaining the right leg in a straight, neutral position.
Following a cardiac catheterization via the femoral artery, the client must remain on bed rest with the affected extremity kept completely straight to prevent hematoma formation and bleeding. When basic care such as a linen change is required, the safest and most appropriate approach is for the nurse to gently assist the client to turn toward the unaffected side (the left side) while strictly maintaining the affected right leg in a straight, neutral position. This provides access for hygiene while protecting the vascular access site.

Step-by-Step Solution

1
Identify the client's post-procedure requirements.
The client had a right femoral cardiac catheterization and requires strict bed rest with the affected right leg kept completely straight.
To prevent hemorrhage and hematoma formation at the high-pressure arterial puncture site.
2
Evaluate the basic care task required.
The client needs immediate perineal care and a linen change due to urinary incontinence.
To maintain skin integrity, prevent infection, and provide basic comfort.
3
Determine the safest method to execute the care.
The client can be turned to the unaffected (left) side by the nurse, as long as the right leg is kept completely straight and supported.
This approach successfully balances the physiological need for arterial site protection with the basic care need for hygiene.

Key Concept

Post-Cardiac Catheterization Basic Care and Positioning
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Topics

Basic Care and Comfort

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