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?

  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.