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Zorluk: OrtaReduction of Risk Potential

A nurse is assessing a client who returned to the telemetry unit 2 hours ago following a left heart catheterization performed via the right femoral artery. Which of the following findings require immediate intervention by the nurse? Select all that apply.

  1. The client reports new-onset, severe lower back pain.Cevap
  2. The client's right foot is pale and the dorsalis pedis pulse is nonpalpable.Cevap
  3. The client is resting in bed with the head elevated to a 60-degree angle.Cevap
  4. D
    The client's most recent arterial blood gas reveals a pH of 7.38 and a PaCO2PaCO_2 of 42 mmHg.
  5. E
    The client reports mild, localized tenderness directly over the femoral insertion site.
  6. F
    The client's urine output has been 180 mL over the past hour.

Cevap

The findings requiring immediate intervention are the new-onset severe lower back pain, the pale foot with a nonpalpable pulse, and the head of the bed elevated to 60 degrees.
The findings requiring immediate intervention are those that indicate a life-threatening complication or a breach of safety protocols. Severe lower back pain is a cardinal sign of retroperitoneal bleeding. A pale foot with an absent pulse indicates acute arterial occlusion, which rapidly compromises tissue perfusion. A head of bed elevated to 60 degrees causes excessive hip flexion, risking disruption of the arterial clot and severe hemorrhage.

Adım Adım Çözüm

1
Analyze the procedure and its associated physiological risks.
The client had a cardiac catheterization via the right femoral artery, placing them at high risk for arterial bleeding, hematoma, retroperitoneal hemorrhage, and neurovascular compromise.
Understanding procedural risks focuses the assessment on recognizing early, life-threatening complications.
2
Evaluate each finding to identify signs of complications.
Severe back pain indicates potential retroperitoneal bleeding. A pale foot with no pulse indicates arterial occlusion. A head of bed at 60 degrees increases femoral artery pressure and bleeding risk.
These three findings represent acute safety risks requiring immediate nursing or medical intervention.
3
Differentiate abnormal findings from expected physiological responses.
Normal ABG values, mild insertion site tenderness, and adequate urine output are all expected or positive findings following this procedure.
Expected findings do not require immediate intervention and represent stable physiological adaptation.

Anahtar Kavram

Reduction of Risk Potential: Post-Cardiac Catheterization Care
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Konular

Reduction of Risk Potential

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