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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Correct Answer is C
Explanation
A. The meningococcal (MCV4) vaccine is typically recommended for preteens and adolescents, usually starting at age 11.
B. The hepatitis B vaccine is typically administered at birth, 1-2 months, and 6-18 months, so a 4-year-old may already have received this vaccine.
C. The varicella (VAR) vaccine is recommended for children at ages 12-15 months and again at 4-6 years, making it appropriate for a 4-year-old child.
D. The Haemophilus influenza type b (Hib) vaccine is usually given to children in a series before 5 years of age, but it is more commonly completed by age 2-3 years. The 4-year-old may already be up to date with this vaccine.
Correct Answer is ["C","D"]
Explanation
A. The child should avoid tub baths or submerging in water for several days post-procedure to reduce the risk of infection and keep the catheter site dry; sponge baths are usually recommended.
B. Keeping the child home for an entire week may be excessive; the duration of home care typically depends on the child's recovery, and many children can return to school sooner if they feel well.
C. Offering clear liquids for the first 24 hours helps ensure the child stays hydrated and allows for easier digestion following anesthesia or sedation.
D. Giving acetaminophen for discomfort is appropriate, as it can help manage any pain or discomfort the child may experience after the procedure, and is usually a recommended practice.