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Zorluk: OrtaBasic Care and Comfort

A client arrives at the medical-surgical unit after a diagnostic cardiac catheterization performed via the right femoral artery. It has been 30 minutes since the procedure concluded. Which of the following actions is most appropriate for the nurse to implement?

  1. A
    Elevate the head of the bed to 60 degrees to facilitate optimal chest expansion and comfort.
  2. Ensure the client remains in a supine position while keeping the right lower extremity completely straight.Cevap
  3. C
    Instruct the client to flex the right knee periodically to prevent stiffness and promote venous circulation.
  4. D
    Assign the unlicensed assistive personnel to monitor the right pedal pulse and insertion site every 15 minutes.

Cevap

Ensure the client remains in a supine position while keeping the right lower extremity completely straight.
Following a femoral artery cardiac catheterization, the standard of care requires the client to remain flat or in a low Fowler's position (head of bed elevated no more than 30 degrees) with the affected extremity kept strictly straight for several hours. This specific positioning minimizes mechanical stress on the groin, maintains the integrity of the newly formed clot, and prevents potentially life-threatening hemorrhage or hematoma formation.

Adım Adım Çözüm

1
Identify the procedure performed and its anatomical access site.
The client underwent a cardiac catheterization via the right femoral artery.
The anatomical approach site dictates the specific postoperative positioning required to maintain hemostasis.
2
Determine the physiological risks associated with femoral artery access.
The primary risk is life-threatening hemorrhage or hematoma formation at the high-pressure arterial puncture site.
The femoral artery is a major vessel, and any mechanical disruption of the newly formed clot can cause severe bleeding.
3
Select the nursing intervention that minimizes mechanical stress on the insertion site.
Keeping the client supine with the affected leg completely straight prevents bending at the groin.
Flexion of the hip or knee increases pressure on the femoral artery and can easily dislodge the clot.
4
Evaluate the distractor options against standard safety and delegation practices.
Elevating the head of the bed or flexing the knee is contraindicated. Delegating vascular assessments to UAP is unsafe.
Strict positioning must be maintained, and only the registered nurse can perform initial postoperative assessments.

Anahtar Kavram

Post-cardiac catheterization positioning and care
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Konular

Basic Care and Comfort

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