Examkin

Soru

Zorluk: ZorReduction of Risk Potential

A practical nurse (PN) is assigned to care for a 78-year-old client who returned to the unit 4 hours ago following a percutaneous coronary intervention (PCI) accessed via the right femoral artery. Which of the following actions by the PN are appropriate to reduce the risk of potential complications? Select all that apply.

  1. Instruct the client to maintain the right leg in a straight position and avoid flexing the hip.Cevap
  2. Assess the right pedal pulse, color, and temperature of the right foot at prescribed intervals.Cevap
  3. Monitor the right groin dressing and surrounding tissue for localized swelling or frank bleeding.Cevap
  4. D
    Administer a prescribed intravenous (IV) push dose of metoprolol if the client develops sudden tachycardia.
  5. E
    Document a blood pressure of 94/56 mm Hg and a heart rate of 112 beats/min as expected post-procedure baseline findings.
  6. F
    Inform the family that the client's sudden onset of confusion is a normal age-related reaction to the procedure's sedation.

Cevap

The correct actions are instructing the client to keep the leg straight, assessing the pedal pulse and neurovascular status, and monitoring the groin dressing for bleeding.
Maintaining the affected leg in a straight position prevents the dislodgment of the clot at the femoral insertion site. Frequent neurovascular checks of the distal extremity ensure that arterial blood flow is not compromised by a thrombosis. Monitoring the groin dressing directly assesses for external bleeding or subcutaneous hematoma formation, allowing for prompt intervention.

Adım Adım Çözüm

1
Identify the primary risks associated with a femoral artery puncture.
Risks include hemorrhage, retroperitoneal hematoma, and distal arterial occlusion.
Understanding the specific procedural risks guides the selection of appropriate nursing interventions.
2
Evaluate the nursing actions that mitigate these specific risks.
Keeping the leg straight prevents clot disruption, while neurovascular checks and site monitoring detect complications early.
These actions directly address the physiologic risks of the PCI procedure and fall within the PN scope of practice.
3
Analyze the remaining options for safety and scope of practice violations.
Administering IV push medications is out of scope. Ignoring borderline vitals or acute confusion compromises patient safety.
Distractors in NCLEX style questions often test the nurse's ability to recognize limits of practice and early warning signs of deterioration.

Anahtar Kavram

Postoperative nursing care following a femoral access procedure involves strict site immobilization, frequent neurovascular monitoring, and prompt escalation of subtle signs of shock or delirium, while operating strictly within the PN scope of practice.
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Reduction of Risk Potential

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