A nurse is caring for a client who just returned from a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
Have the client remain in bed up to 6 hr.
Check peripheral pulses in the affected extremity.
Place the client in high-Fowler's position.
Keep the client's hip and leg extended.
Measure the client's vital signs every 4 hr.
Correct Answer : A,B,D,E
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.
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Related Questions
Correct Answer is A
Explanation
A. It is recommended to replace the child's toothbrush after 24 hours of starting antibiotics to prevent reinfection or spreading the bacteria.
B. A child with acute group A B-hemolytic streptococci should remain home from school until they have been on antibiotics for at least 24 hours, not for a full week, to reduce the risk of spreading the infection.
C. Warm compresses may be used to alleviate discomfort associated with sore throats or swollen glands; there is no contraindication to their use in this context.
D. Intramuscular injections are not a standard treatment for this condition; antibiotics are typically administered orally unless there are complications requiring different management.
Correct Answer is C
Explanation
A. Encouraging the adolescent to spend more time alone may reinforce their withdrawal and does not promote social interaction or engagement.
B. Assigning the adolescent as a leader may increase anxiety and exacerbate their withdrawal rather than encourage socialization.
C. One-on-one counseling can provide a safe space for the adolescent to express feelings and explore the reasons for their withdrawal, which is a supportive and therapeutic intervention.
D. Focusing solely on academic achievements may lead to further isolation and does not address the need for social skills development and peer interaction.
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