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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Using a booster seat until the child reaches the appropriate height for a seatbelt is correct and aligns with safety guidelines for child passengers.

B. Allowing a child to ride in the front seat while still using a booster seat is unsafe; children should remain in the back seat until they are at least 13 years old.

C. Ensuring that the child wears a helmet while riding a bicycle is an important safety measure and demonstrates understanding of injury prevention.

D. Teaching the child to avoid running into the street without looking shows awareness of pedestrian safety and the need for supervision and education about traffic safety.

A. Contact child protective services to intervene in the family since the child's parent does not seem adequately prepared to manage the client's illness at home. B. Write out a detailed schedule of the child's medications and a list of their healthcare providers' addresses and phone numbers in case they should need it. C. Empower the child's parent to help manage the asthma by offering comprehensive education on the condition, treatment plan, and managing potential complications at home. D. Print out a copy of the asthma action plan and thoroughly review it with the child and the school nurse prior to discharge.

Correct Answer is C

Explanation

A. While child protective services may be necessary in cases of abuse or neglect, it is premature to take this action without understanding the family's dynamics and assessing the parent’s knowledge and skills regarding asthma management.

B. Providing a detailed medication schedule and healthcare provider information is helpful but does not actively engage the parent in the child's care or education about asthma management.

C. Empowering the parent through comprehensive education will foster engagement and collaboration, equipping them with the knowledge needed to support their child's asthma management effectively at home.

D. Reviewing the asthma action plan is important, but it should involve both the child and parent to ensure that the parent is actively engaged and understands how to implement the plan.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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