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Question

Difficulty: EasyReduction of Risk Potential

A 65-year-old client is transferred to the telemetry unit immediately following a diagnostic cardiac catheterization accessed via the right femoral artery. The client is awake, reports feeling hungry, and has stable vital signs. The right pedal pulse is palpable. To reduce the risk of severe hemorrhage or hematoma at the puncture site, which positioning directive must the nurse enforce?

  1. Maintain strict bedrest with the right leg kept completely straight and immobile.Answer
  2. B
    Elevate the head of the bed to a 60-degree angle to allow the client to eat a meal safely.
  3. C
    Assist the client into a side-lying position with the knees flexed to reduce lower back pain.
  4. D
    Prioritize assisting the client to the bedside commode to prevent bladder distention.

Answer

Maintain strict bedrest with the right leg kept completely straight and immobile.
Following a femoral artery access procedure, maintaining the affected extremity completely straight and keeping the client on strict bedrest is critical. This specific position prevents tension and flexion at the groin, allowing a stable clot to form and preventing life-threatening arterial bleeding or hematoma development at the high-pressure puncture site.

Step-by-Step Solution

1
Identify the procedure and access site from the clinical vignette.
The client underwent a cardiac catheterization via the right femoral artery.
Understanding the access site is crucial for anticipating specific post-procedure complications.
2
Determine the highest priority risk associated with this specific procedure.
The greatest immediate risk is arterial hemorrhage or hematoma formation at the high-pressure femoral puncture site.
Arterial access sites require meticulous care to ensure a stable clot forms and prevents life-threatening blood loss.
3
Select the nursing intervention that directly mitigates this risk.
Keeping the affected leg straight and maintaining strict bedrest prevents flexion at the groin, protecting the puncture site.
Any bending at the hip increases intra-abdominal pressure and mechanical stress on the artery, which can easily dislodge the clot.

Key Concept

Post-procedure positioning to prevent arterial bleeding
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Topics

Reduction of Risk Potential

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