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Zorluk: OrtaBasic Care and Comfort

A nurse is caring for an older adult client who returned to the inpatient unit 1 hour ago following a left-sided cardiac catheterization accessed via the femoral artery. The client is experiencing lower back discomfort from prolonged immobility, has been incontinent of urine, and is intermittently reaching toward the groin dressing. Which of the following nursing interventions are appropriate? Select all that apply.

  1. A
    Elevate the head of the bed to 60 degrees to alleviate the client's lower back pain.
  2. B
    Assign the unlicensed assistive personnel to assess the left pedal pulse and femoral insertion site.
  3. Utilize a fracture bedpan for elimination to avoid excessive flexion of the client's hips.Cevap
  4. Provide a back massage by gently rolling the client slightly toward the right side while keeping the left leg straight.Cevap
  5. E
    Apply soft bilateral wrist restraints to prevent the client from disturbing the femoral insertion site dressing.
  6. Place a trochanter roll alongside the client's left leg to maintain neutral alignment and prevent external rotation.Cevap

Cevap

The correct interventions are utilizing a fracture bedpan, providing a back massage by rolling the client slightly to the unaffected side, and placing a trochanter roll alongside the affected leg.
Utilizing a fracture bedpan safely manages urinary incontinence while preventing excessive hip flexion. Providing a back massage by slightly rolling the client to the unoperated side relieves back pain while keeping the affected leg completely straight. Applying a trochanter roll prevents external hip rotation, maintaining the neutral alignment strictly required to prevent stress on the femoral puncture site.

Adım Adım Çözüm

1
Identify the client's current clinical situation and primary risks.
The client recently underwent a left femoral cardiac catheterization, which requires the left leg to remain strictly straight to prevent arterial hemorrhage.
Understanding the procedural constraints is essential before implementing any comfort or hygiene measures.
2
Evaluate each intervention for safety regarding the femoral puncture site.
Using a fracture bedpan, slight rolling to the unoperated side, and placing trochanter rolls all successfully maintain the required straight alignment of the left leg.
Any intervention that flexes the affected hip or disturbs the clot can cause severe, life-threatening bleeding.
3
Identify incorrect or unsafe interventions.
Elevating the head of the bed to 60 degrees bends the hip dangerously. Delegating pulse checks is outside the scope of practice for unlicensed personnel. Restraining the client skips required alternative safety measures.
Nursing actions must strictly adhere to scope of practice, safety protocols, and post-procedure guidelines.

Anahtar Kavram

Providing basic care, hygiene, and non-pharmacologic comfort measures while strictly adhering to post-procedural positioning requirements to prevent complications.
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Konular

Basic Care and Comfort

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