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","B","E"]
Explanation
A. Increased risk-taking behaviors are common as adolescents may feel invulnerable and engage in dangerous activities without considering the consequences.
B. Greater incidence of accidental injuries is often a result of risk-taking behaviors, which can be influenced by feelings of invulnerability.
C. Reduced mental health issues is incorrect as feelings of invulnerability can lead to increased stress and anxiety, negatively impacting mental health.
D. Improved social relationships are not guaranteed; feelings of invulnerability may actually lead to conflict or isolation if risk-taking behaviors are harmful.
E. Higher likelihood of substance abuse can result from a belief in invulnerability, leading adolescents to underestimate the risks associated with drug and alcohol use.
F. Enhanced academic performance is not directly linked to feelings of invulnerability and may suffer due to distractions from risky behaviors.
Correct Answer is C
Explanation
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
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