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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Enforcing strict bed rest without any physical activity can lead to feelings of isolation and boredom, which may negatively affect the child's well-being and engagement.
B. Allowing the child to decorate their hospital room with personal items fosters a sense of ownership and comfort, helping to promote emotional well-being and engagement during hospitalization.
C. Limiting visits can increase feelings of loneliness and anxiety in the child, which is not conducive to their emotional health; maintaining social connections is important for well-being.
D. Using medical terms may confuse the child and does not support their understanding or engagement; explanations should be age-appropriate and easily understood.
Correct Answer is C
Explanation
A. Secondary prevention involves early detection and prompt intervention in health issues that have already occurred; providing education about stress does not fall under this category.
B. Suicide prevention is a specific aspect of mental health care and is not directly related to general stress education.
C. Primary prevention aims to prevent the onset of health issues and promote health and well-being, making the education on stress and its effects a form of primary prevention.
D. Tertiary prevention focuses on rehabilitation and management of existing diseases, which does not apply to teaching about stress effects.