Practice Question
A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
Answer Choices:
Correct Answer:
Have the client remain in bed up to 6 hr.
Rationale:
✅ A. Have the client remain in bed up to 6 hours.
🛌 After cardiac catheterization—especially when the femoral artery is used—the patient is typically placed on strict bedrest for 4–6 hours to prevent bleeding or hematoma formation at the insertion site.
🛌 During this time, the nurse must monitor for signs of bleeding, such as swelling, pain, or visible blood at the site.
🛌 Ambulation too soon can lead to arterial disruption, especially if the catheter site is not adequately clotted or sealed.
🛌 The duration of bedrest may be modified based on the size of the sheath used, closure device applied, and provider-specific protocols.
✅ B. Check peripheral pulses in the affected extremity.
🛌 It is crucial to assess the circulatory status of the limb used for catheter access (typically the leg) by checking pedal or posterior tibial pulses.
🛌 Diminished or absent pulses may indicate vascular occlusion, thrombosis, or arterial spasm, which are serious complications of catheterization.
🛌 Additional signs like cool skin, pallor, or delayed capillary refill should also be assessed and reported immediately.
🛌 Frequent checks (e.g., every 15 minutes initially) are essential in the first 1–2 hours post-procedure, then spaced as the patient stabilizes.
✅ D. Keep the client’s hip and leg extended.
🛌 Keeping the affected extremity straight and immobilized minimizes strain on the puncture site and helps prevent bleeding or hematoma formation.
🛌 Flexing the hip, especially in the first 4–6 hours, can place pressure on the catheter site and disrupt clot formation, increasing the risk of hemorrhage.
🛌 Positioning the client with the head of the bed no higher than 30 degrees supports comfort while maintaining safe alignment.
🛌 This is especially important for children and restless patients, who may require soft restraints or parental assistance to keep the leg still.
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This question is from RN ATI Pediatrics Unit II Exam which contains 59 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 5