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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.)

A.

Have the client remain in bed up to 6 hr.

B.

Check peripheral pulses in the affected extremity.

C.

Place the client in high-Fowler's position.

D.

Keep the client's hip and leg extended.

E.

Measure the client's vital signs every 4 hr.

Question Solution

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 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 A

Explanation

A. Furosemide is a loop diuretic that can cause potassium loss; therefore, it is essential for the child to eat potassium-rich foods to prevent hypokalemia.

B. Taking furosemide at bedtime is not advisable due to the increased risk of nocturia and sleep disturbances from frequent urination.

C. Aspirin is not recommended without medical guidance, especially for children, as it can increase the risk of Reye's syndrome.

D. Expecting swelling in the hands and feet contradicts the purpose of furosemide, which is to reduce fluid overload; parents should report any unexpected swelling to the healthcare provider.

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