Nursing Care and Interventions Flashcards

A client returns from cardiac catheterization via the right femoral artery. A pulsatile expanding mass is found at the puncture site. What is required immediately?

Answer: Apply immediate manual pressure at the site and notify the physician urgently

A pulsatile expanding mass indicates arterial bleeding or pseudoaneurysm requiring immediate manual pressure and urgent physician notification.

A client has a chest tube connected to water seal drainage. The water in the water seal chamber stops oscillating (tidaling). What does this indicate?

Answer: Either the lung has re-expanded or the tube is kinked/blocked, assess further

Cessation of tidaling can mean the lung has re-expanded (normal) or the tube is kinked/blocked. Further assessment is needed.

A client is being prepared for a paracentesis. Which nursing intervention has the highest priority?

Answer: Instructing the client to void to empty the bladder

Having the client void before paracentesis prevents bladder injury during the procedure, as the needle is inserted near the suprapubic region.

A pressure injury has 80% black necrotic tissue. Which type of debridement is most appropriate?

Answer: Sharp debridement by a wound care specialist

A wound bed with 80% hard/thick black eschar requires sharp debridement by a qualified wound care specialist for rapid, effective necrotic tissue removal.

When performing tracheostomy care, which action is included in correct technique?

Answer: Using sterile technique, cleaning the inner cannula with hydrogen peroxide followed by sterile water or saline rinse

Tracheostomy inner cannula care requires sterile technique with hydrogen peroxide to remove secretions and sterile saline rinse to remove the peroxide residue.

A client in the PACU has respiratory rate 8 breaths per minute and SpO2 91% after abdominal surgery. What is the priority nursing action?

Answer: Stimulate the client to breathe by calling their name and applying tactile stimulation if needed

Post-anesthesia respiratory depression requires immediate stimulation of the client to breathe, supplemental oxygen, and readiness for additional intervention.