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 D
Explanation
A. Using dessert as a reward for eating vegetables can create a negative association with healthy foods, making them seem like a chore rather than a normal part of the diet.
B. Labeling foods as "good" and "bad" can lead to guilt or shame around eating, which is counterproductive to fostering a healthy relationship with food.
C. Encouraging children to eat all the food on their plate, regardless of hunger cues, can promote overeating and a disconnection from their body's signals.
D. Offering a variety of foods and allowing children to choose from healthy options encourages autonomy, helps them explore new foods, and supports a positive relationship with food.
Correct Answer is C
Explanation
A. By age 6, while children can dress themselves, they may still need assistance with more complex grooming tasks, making this statement too absolute.
B. Counting backwards from 20 to 1 is typically expected by age 8, not age 7, indicating this statement is inaccurate regarding cognitive development.
C. Engaging in motor activities that require balance, such as jumping rope, is appropriate for children around age 6, demonstrating the expected physical development in this age group.
D. While children can use simple tools, mastery and effective use of tools like a screwdriver or hammer are more typical around ages 8 to 10, making this statement premature for age 6.
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