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Difficulty: MediumBasic Care and Comfort

A nurse is caring for a client who returned to the medical unit 2 hours ago following a cardiac catheterization accessed via the right femoral artery. The client has stable vital signs, no evidence of bleeding at the insertion site, and reports mild lower back stiffness from lying flat. Which of the following nursing actions is the most appropriate to promote comfort?

  1. A
    Elevate the head of the bed to a 45-degree angle to decrease tension on the lower back muscles.
  2. B
    Instruct the unlicensed assistive personnel to assist the client into a side-lying position with both knees flexed.
  3. Slide a small, supportive rolled towel under the client's lumbar spine while maintaining the right leg in a completely straight position.Answer
  4. D
    Encourage the client to actively bend and straighten the right leg to alleviate the muscle stiffness.

Answer

Slide a small, supportive rolled towel under the client's lumbar spine while maintaining the right leg in a completely straight position.
Following a femoral cardiac catheterization, the affected extremity must be kept straight to prevent bleeding or hematoma formation at the puncture site. Placing a small rolled towel under the lumbar spine provides lower back support and relieves discomfort while safely maintaining the required straight-leg position and bed rest.

Step-by-Step Solution

1
Analyze the client's clinical situation and procedural mobility restrictions.
The client had a right femoral cardiac catheterization, which requires the right leg to remain completely straight and the head of the bed to remain low (usually flat or less than 30 degrees) to prevent hemorrhage.
Understanding post-procedure constraints is essential before implementing any comfort measures.
2
Evaluate the client's request for comfort against the identified safety restrictions.
The client is experiencing lower back stiffness, a common side effect of prolonged supine positioning, but interventions cannot involve bending the right hip or knee.
Basic care and comfort must be balanced with the prevention of procedural complications.
3
Select the nursing intervention that effectively provides comfort without violating the safety constraints.
Placing a small lumbar roll provides support to the natural curve of the spine while keeping the femoral insertion site straight and undisturbed.
This is a safe, non-pharmacological comfort measure that adheres to strict post-cardiac catheterization protocols.

Key Concept

Post-procedure comfort and positioning constraints following femoral artery access
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Topics

Basic Care and Comfort

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