During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to:
A. Elevate the client’s bed at 45°.
B. Instruct the client to cough and deep breathe every 2 hours.
C. Frequently monitor the client’s apical pulse and blood pressure.
D. Monitor client’s temperature every hour.
Correct Answer: C. Frequently monitor the client’s apical pulse and blood pressure.
Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. The apical pulse is taken to detect arrhythmias related to cardiac irritability. During the procedure, a nurse is assigned to monitor vital signs. After the procedure, the nurse is also responsible for ensuring that the access site is not bleeding and the distal extremity pulses are intact.
Option A: Patients should be kept lying flat for several hours after the procedure so that any serious bleeding can be avoided. Identification of the bleeding source is essential for patients with continued hemodynamic deterioration. These life-threatening bleeds are more frequent when the artery is punctured above the inguinal ligament. Most patients are managed with a reversal of anticoagulation, application of manual compression and volume resuscitation, and observation.
Option B: Coughing and deep breathing every 2 hours is unnecessary. For any patient, the complication rate is dependent on multiple factors and is dependent on the demographics of the patient, vascular anatomy, comorbid conditions, clinical presentation, the procedure being performed, and the experience of the operator. The complications can be minor as discomfort at the site of catheterization to major ones like death.
Option D: Temperature can be monitored for every shift. Cardiac catheterization is performed using sterile technique, and local or systemic infection is extremely rare. Routine prophylaxis for endocarditis is not recommended during cardiac catheterization procedures.