A nurse is caring for a client who returned to the telemetry unit 1 hour ago following a diagnostic cardiac catheterization via the right femoral artery. Which of the following interventions should the nurse include in the client's immediate plan of care? Select all that apply.
- Assess the right dorsalis pedis pulse, capillary refill, and extremity temperature.Answer
- BElevate the head of the bed to 60 degrees to promote optimal respiratory expansion.
- Evaluate the client for new-onset lower back pain, flank pain, or sudden hypotension.Answer
- DDelegate the immediate post-procedure vital sign measurements to the unlicensed assistive personnel.
- Encourage increased oral fluid intake to assist with the renal excretion of radiopaque contrast.Answer
Answer
The correct interventions are assessing the distal pulses/temperature, evaluating for lower back/flank pain, and encouraging fluid intake.
Following a femoral cardiac catheterization, the nurse's priority is reducing the risk of arterial bleeding and distal ischemia. The nurse must frequently assess neurovascular status (pulses, temperature, and capillary refill) distal to the puncture site to ensure adequate perfusion. Assessing for new-onset back or flank pain is critical, as this is a primary and early indicator of retroperitoneal hemorrhage, a life-threatening complication. Finally, radiopaque contrast dye used during the procedure is nephrotoxic; encouraging fluid intake promotes diuresis and reduces the risk of acute kidney injury.
Step-by-Step Solution
Key Concept
Post-Cardiac Catheterization Risk Reduction