A nurse is caring for a client who is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?
Explanation & Rationale
A. Instruct the client to flex the right knee every 30 min: Flexing the knee can increase the risk of bleeding or hematoma formation at the femoral access site and is generally avoided immediately after the procedure. B. Elevate the head of the client's bed to 45°: Elevating the head more than 30 degrees can put pressure on the femoral site and increase bleeding risk; typically, the head of the bed is kept flat or slightly elevated. C. Change the client’s dressing 4 hr following the procedure: The initial dressing is usually kept intact for at least 24 hours unless it becomes saturated, as frequent dressing changes can disrupt the site and increase infection risk. D. Assess the client’s peripheral pulses every 15 min: Frequent monitoring of peripheral pulses is critical to detect early signs of impaired circulation or complications such as arterial occlusion or hematoma at the catheter insertion site.