Examkin

Question

Difficulty: HardReduction of Risk Potential

A nurse is caring for a client who returned to the telemetry unit thirty minutes ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following nursing interventions are necessary to reduce the risk of physiological complications? (Select all that apply.)

  1. A
    Position the client in a high-Fowler's position to promote lung expansion after conscious sedation.
  2. Assess the right pedal pulse, skin color, and sensation of the extremity every fifteen minutes.Answer
  3. C
    Monitor the client's vital signs specifically for a widening pulse pressure and bradycardia as early signs of bleeding.
  4. Instruct the client to keep the right leg strictly extended and avoid flexing the hip.Answer
  5. E
    Delegate the routine fifteen-minute femoral insertion site assessments to the unlicensed assistive personnel (UAP).
  6. Ensure the continuous intravenous fluid infusion is maintained as prescribed to promote contrast dye excretion.Answer

Answer

The correct interventions are assessing the right pedal pulse frequently, instructing the client to keep the right leg strictly extended, and maintaining the continuous intravenous fluid infusion.
The correct actions directly mitigate the most common and severe complications following a femoral percutaneous coronary intervention. Keeping the leg extended prevents clot disruption, frequent neurovascular checks ensure distal perfusion is maintained, and adequate intravenous hydration prevents contrast-induced acute kidney injury.

Step-by-Step Solution

1
Identify the procedure and the primary risks associated with it.
The client underwent a percutaneous coronary intervention via the right femoral artery. Major risks include femoral hemorrhage, retroperitoneal bleeding, arterial occlusion, and contrast-induced nephropathy.
Understanding procedure-specific risks is essential for prioritizing preventative nursing interventions.
2
Evaluate the positioning and mobility interventions.
The client must keep the affected leg straight and avoid hip flexion (no high-Fowler's position) to prevent clot disruption at the femoral access site.
Hip flexion increases pressure on the femoral artery, which can dislodge the hemostatic clot.
3
Analyze the physiological monitoring parameters.
The nurse must assess distal perfusion frequently. Early signs of hypovolemic shock include tachycardia and a narrowing pulse pressure, making the option suggesting bradycardia and widening pulse pressure incorrect.
Prompt detection of arterial occlusion or internal bleeding allows for immediate life-saving interventions.
4
Evaluate the fluid management and delegation options.
Intravenous fluids must be maintained to flush nephrotoxic contrast dye. Post-procedure assessments cannot be delegated to unlicensed assistive personnel.
Hydration prevents acute kidney injury. Post-operative assessments require registered nurse clinical judgment.

Key Concept

Reduction of Risk Potential: Post-Cardiac Catheterization Care
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic