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Zorluk: KolayReduction of Risk Potential

A client is admitted to the telemetry unit immediately after undergoing a cardiac catheterization using the right femoral artery approach. Which actions are essential for the nurse to take to minimize the risk of complications? Select all that apply.

  1. Evaluate the right pedal pulse and capillary refill.Cevap
  2. Keep the client's right lower extremity completely straight.Cevap
  3. C
    Position the head of the bed at a 60-degree angle to promote client comfort.
  4. D
    Delegate the initial post-procedure vital sign measurements to the unlicensed assistive personnel (UAP).
  5. Inspect the groin puncture site for any signs of bleeding or swelling.Cevap
  6. F
    Delay reporting mild tachycardia as long as the client's blood pressure remains stable.

Cevap

The essential actions are to evaluate the distal pulses and capillary refill, keep the affected leg straight, and inspect the puncture site for bleeding or swelling.
Minimizing complications after a femoral cardiac catheterization requires interventions focused on maintaining hemostasis and ensuring adequate distal tissue perfusion. Evaluating distal pulses and inspecting the puncture site allow for the early detection of arterial occlusion or bleeding. Keeping the affected leg straight prevents the dislodgement of the clot at the femoral artery site.

Adım Adım Çözüm

1
Identify the procedure and the specific access site.
The client had a cardiac catheterization via the right femoral artery.
The access site determines the specific post-procedure positioning and monitoring requirements needed to prevent hemorrhage.
2
Determine the priority assessments and interventions for this specific site.
The client requires frequent site checks, distal neurovascular assessments, and the affected leg must remain straight.
These actions directly monitor for and prevent the most common complications: bleeding, hematoma formation, and arterial occlusion.
3
Evaluate each option against safe post-procedure protocols.
Elevating the head of the bed too high, delegating the initial assessment, and ignoring early signs of shock are identified as unsafe actions.
These incorrect actions violate fundamental principles of proper positioning, safe delegation, and the early recognition of complications.

Anahtar Kavram

Post-Cardiac Catheterization Care and Complication Prevention
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Konular

Reduction of Risk Potential

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