A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

Measure the client's vital signs every 4 hr.

Place the client in high-Fowler's position.

Keep the client's affected extremity straight.

Ensure bedrest is maintained for the prescribed time.

Check peripheral pulses in the affected extremity.

Answer and Explanation

Correct Answer : C,D,E

A. Vital signs should be monitored more frequently than every 4 hours immediately after cardiac catheterization, often every 15 minutes initially.
B. The client should be positioned supine or with minimal elevation to avoid stress on the catheter insertion site, not in high-Fowler’s position.
C. Keeping the affected extremity straight helps prevent bleeding and dislodgement of the vascular closure.
D. Bedrest for the prescribed time is essential to promote hemostasis and prevent complications.
E. Checking peripheral pulses ensures adequate circulation and detects possible vascular complications early.

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Correct Answer is ["325"]

Explanation

Total fluid volume for 24 hours = 5,200 mL

First 8-hour period = receive half of total volume
5,200 ÷ 2 = 2,600 mL

Time = 8 hours

Calculation:

2,600 mL ÷ 8 hr = 325 mL/hr

Answer: 325 mL/hr

A. Open the airway using a jaw-thrust maneuver. B. Determine effectiveness of ventilator efforts. C. Establish IV access. D. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.

Correct Answer is ["A","B","C","D","E"]

Explanation

A (Airway): Open the airway using a jaw-thrust maneuver is the first action to ensure the airway is patent, especially important in trauma to avoid cervical spine injury.

B (Breathing): Determine effectiveness of ventilator efforts comes next to assess if the client is ventilating adequately.

C (Circulation): Establish IV access is part of restoring and maintaining circulation, allowing for fluid resuscitation or medication administration.

D (Disability): Perform a Glasgow Coma Scale assessment evaluates neurological function to determine the level of consciousness.

E (Exposure): Remove clothing for a thorough assessment ensures the nurse can identify all injuries and prevent missing any life-threatening conditions.

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A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["325"]

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. Use all the steps.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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