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Zorluk: OrtaBasic Care and Comfort

A practical nurse is caring for a client who is recovering from a diagnostic cardiac catheterization performed via the right femoral artery approach. The client reports mild lower back discomfort and requests a change in position. Which action should the nurse take to promote comfort while maintaining safety?

  1. Elevate the head of the bed to 15 degrees while ensuring the right leg remains completely straight.Cevap
  2. B
    Assist the client into a high-Fowler's position to stretch and relieve the lower back muscles.
  3. C
    Place a rolled blanket directly under the client's right knee to reduce tension on the lower back.
  4. D
    Delegate the assessment of the right pedal pulse and puncture site to an unlicensed assistive personnel (UAP) while preparing comfort measures.

Cevap

Elevate the head of the bed to 15 degrees while ensuring the right leg remains completely straight.
The correct action balances the client's need for comfort with strict safety parameters. After a femoral artery approach, the hip must remain un-flexed to prevent bleeding. Elevating the head of the bed up to 30 degrees (15 degrees in this case) is permissible and can help alleviate lower back pain without compromising the arterial puncture site.

Adım Adım Çözüm

1
Analyze the client's clinical situation and current procedure.
The client had a cardiac catheterization via the right femoral artery, which carries a high risk of arterial bleeding at the groin site.
Identifying the procedure guides the necessary post-operative restrictions and safety precautions.
2
Evaluate the standard positioning constraints for a femoral access site.
The standard protocol requires keeping the affected leg straight and maintaining the head of the bed at an elevation no greater than 30 degrees.
Any significant flexion at the hip or groin can dislodge the clot and cause severe bleeding or a hematoma.
3
Determine the safest way to address the client's lower back discomfort within the given constraints.
Elevating the head of the bed to 15 degrees is within the safe limit (less than 30 degrees) and helps relieve back strain without compromising the straight alignment of the right leg.
This balances the client's basic comfort needs with strict physiological safety requirements.

Anahtar Kavram

Post-Procedure Positioning and Comfort
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Konular

Basic Care and Comfort

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