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    Sp26 504w advanced med surg proctored exam (Massachusetts college)

    A nurse is caring for a client who returned from the catheterization laboratory (cath lab) to recover on the cardiac intermediate care unit status post radial approach transcatheter aortic valve replacement (TAVR). Which intervention would the nurse include in the client's care?

    Explanation & Rationale

    A. Perform range of motion (ROM) exercises: While early mobility is important, ROM exercises involving the affected arm should be limited initially to prevent disruption of the radial artery access site. Encouraging movement too soon could increase bleeding or hematoma formation. B. Assess the insertion site: Frequent assessment of the radial artery access site is essential after a TAVR via the radial approach. The nurse monitors for bleeding, hematoma, swelling, discoloration, or compromised distal circulation, ensuring early detection and management of vascular complications. C. Maintain NPO status for 2-6 hours: NPO status is typically required for procedures involving sedation, anesthesia, or femoral access to prevent aspiration. After a radial approach TAVR, the client may resume oral intake sooner, and prolonged NPO is usually unnecessary. D. Log roll the client to use the bedpan: Log-rolling is used to protect the spine or after certain surgeries. For a radial artery access site, rolling the client is not indicated and does not reduce risk at the wrist. Care should focus on protecting the arm and monitoring vascular integrity rather than body positioning maneuvers.

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