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. Assess the client's peripheral pulses every 15 min. Frequent assessment of peripheral pulses, especially in the affected extremity, is essential to monitor for signs of arterial occlusion, hematoma, or compromised circulation following a femoral catheterization. B. Change the client's dressing 4 hr following the procedure. The initial pressure dressing should not be disturbed unless there are signs of bleeding or saturation. Routine dressing changes this soon can disrupt the clotting process at the insertion site. C. Instruct the client to flex the right knee every 30 min. The client should keep the affected leg straight to prevent disrupting the insertion site. Flexing the knee can increase the risk of bleeding and compromise the integrity of the puncture site. D. Elevate the head of the client's bed to 45°. Elevating the head of the bed too high can increase abdominal pressure on the femoral site, risking bleeding. The bed should be kept no higher than 30° to reduce stress on the insertion area.