Examkin

Soru

Zorluk: KolayReduction of Risk Potential

An older adult client is admitted to the medical-surgical unit immediately after undergoing a diagnostic cardiac catheterization using the right femoral approach. Which action must the practical nurse (PN) implement to decrease the risk of a post-procedural hemorrhage?

  1. Maintain the client on bed rest while keeping the right leg completely straight.Cevap
  2. B
    Elevate the head of the client's bed to a 60-degree angle to promote comfort.
  3. C
    Document a gradually rising heart rate as an expected response to the dye.
  4. D
    Apply a warm, moist compress directly over the right groin area.

Cevap

Maintain the client on bed rest while keeping the right leg completely straight.
Following a femoral cardiac catheterization, the insertion site is at a high risk for arterial bleeding. Keeping the affected leg straight and maintaining bed rest prevents unnecessary pressure, flexion, and movement at the puncture site, ensuring the arterial clot remains stable and intact.

Adım Adım Çözüm

1
Identify the procedure and its primary immediate complication risk.
The procedure is a femoral cardiac catheterization, which carries a high risk of arterial bleeding at the groin insertion site.
Understanding the procedural risks guides prioritizing the most appropriate protective nursing intervention.
2
Determine how physical positioning impacts the femoral artery.
Bending the hip or moving the leg puts mechanical stress on the puncture site, which can disrupt clot formation.
Maintaining the structural integrity of the newly formed clot is essential to prevent hemorrhage.
3
Select the nursing action that mitigates this specific risk.
Keeping the right leg entirely straight on bed rest minimizes hip flexion and protects the puncture site.
This is the standard evidence-based intervention to prevent post-catheterization bleeding.

Anahtar Kavram

Post-procedure Positioning and Risk Reduction
Tahmini Süre:45s
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Konular

Reduction of Risk Potential

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