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Zorluk: ZorBasic Care and Comfort

A nurse is caring for an older adult client who is 3 hours post-percutaneous coronary intervention (PCI) via a right femoral artery approach. The client, who has a history of osteoarthritis, reports severe lower back stiffness and requests to sit upright or get out of bed. Which intervention should the nurse implement to promote comfort while ensuring client safety?

  1. A
    Turn the client to a left side-lying position and flex the right hip to 45 degrees to stretch the lumbar muscles.
  2. B
    Explain that the stiffness is a normal part of the aging process with osteoarthritis and no position changes are permitted during bedrest.
  3. C
    Elevate the head of the bed to 60 degrees and place a soft pillow under the client's knees to relieve lower back tension.
  4. Maintain the head of the bed elevated no more than 30 degrees and slide a small, rolled towel under the client's lumbar spine.Cevap

Cevap

The correct action is to maintain the head of the bed elevated no more than 30 degrees and slide a small, rolled towel under the client's lumbar spine.
Following a femoral artery puncture, the client must remain on strict bedrest with the affected leg completely straight for several hours to prevent arterial bleeding or hematoma formation. The head of the bed should not be elevated more than 30 degrees to avoid placing undue pressure on the femoral insertion site. Placing a small, rolled towel or lumbar roll under the lower back safely supports the natural curvature of the spine and alleviates muscle stiffness without compromising the vascular access site.

Adım Adım Çözüm

1
Analyze the client's current clinical status and procedure.
The client is 3 hours post-PCI via the right femoral artery.
Identifying the procedure dictates the specific safety parameters for positioning.
2
Determine the required physiological constraints for this procedure.
The right leg must remain completely straight, and the head of the bed cannot be elevated more than 30 degrees.
These restrictions are mandatory to prevent arterial bleeding or hematoma formation at the femoral puncture site.
3
Evaluate the client's request against the safety constraints.
Sitting upright (high-Fowler's) or getting out of bed violates the safety constraints and is contraindicated.
Flexing the groin increases intra-abdominal and groin pressure, risking severe hemorrhage.
4
Select a safe basic care intervention to alleviate lower back stiffness.
Placing a small, rolled towel under the lumbar spine provides comfort while keeping the head of the bed low and the right leg straight.
This intervention respects the anatomical curve of the spine without compromising the vascular access site.

Anahtar Kavram

Safe positioning and comfort measures following femoral artery access
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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