Safe and Effective Care Environment—Management of Care

A nurse is caring for a client in the immediate post–cardiac catheterization period. Which intervention should the nurse include in the client’s care?

Posted on by NCLEX.ME Nurse
  1. monitor vital signs every 30 minutes for the first 2 hours
  2. assess the insertion site
  3. maintain the client in a prone position
  4. keep the client NPO for 2 hours
Number 2 is correct.
Rationale: Assessment of the insertion site for bleeding is a priority. Should bleeding occur, additional compression may be needed. Vital signs are monitored every 15 minutes for 2 hours after the procedure, every 30 minutes during the next 2 hours, and then every hour for 2 hours. The head of the bed may be elevated up to 30 degrees. Clients post-catheterization may eat and drink as tolerated.
NCLEX.ME Nurse