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Soru

Zorluk: OrtaBasic Care and Comfort

A practical nurse is providing care for a client who is on strict bed rest following a left femoral cardiac catheterization. The client requires assistance with hygiene, elimination, and comfort. Which of the following basic care interventions should the nurse implement? (Select all that apply)

  1. Assist the client to use a fracture bedpan while keeping the left leg completely straight.Cevap
  2. B
    Raise the head of the bed to a high-Fowler's position while the client is eating a meal.
  3. Provide a complete bed bath and assist with oral hygiene while keeping the head of the bed flat.Cevap
  4. D
    Turn the client onto the left side by bending the left knee to wash the client's back.
  5. E
    Delegate the initial observation of the femoral puncture site for bleeding to the unlicensed assistive personnel (UAP).
  6. Support the client's lower back with a small rolled towel to reduce discomfort.Cevap

Cevap

The nurse should assist the client to use a fracture bedpan while keeping the left leg straight, provide hygiene care while keeping the bed flat, and support the lower back with a small rolled towel.
Following a femoral approach cardiac catheterization, the client must remain supine or in a low-Fowler's position (head elevated 30 degrees or less) with the affected leg completely straight to prevent bleeding. Assisting with a fracture bedpan, providing hygiene while flat, and using a lumbar support towel all safely meet the client's basic care and comfort needs while adhering to these critical positioning restrictions.

Adım Adım Çözüm

1
Identify the procedural constraints for a femoral cardiac catheterization.
The client must remain on bed rest with the affected leg (left) completely straight and the head of the bed elevated no more than 30 degrees.
Flexing the hip or knee on the affected side increases the risk of arterial bleeding and hematoma.
2
Evaluate each intervention against the positioning constraints.
Interventions that maintain a straight leg and flat or low-Fowler's position are safe.
This ensures the client's basic hygiene, elimination, and comfort needs are met without compromising the surgical site.
3
Determine appropriate delegation of tasks.
Assessment of the puncture site remains the responsibility of the nurse.
UAPs are not licensed to perform clinical assessments, especially for high-risk post-procedure complications.

Anahtar Kavram

Basic care and comfort for clients with strict post-procedure mobility and positioning restrictions.
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Konular

Basic Care and Comfort

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