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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 ["C","D"]

Explanation

A. Object permanence is a cognitive ability typically developed during the sensorimotor stage (0-2 years), not during the concrete operational stage (7-11 years).

B. Egocentric thinking is characteristic of the preoperational stage (2-7 years) and decreases as children enter the concrete operational stage.

C. The ability to perform logical operations on concrete objects is a hallmark of the concrete operational stage, where children can think logically about physical objects and events.

D. Understanding the concept of conservation, which refers to recognizing that quantity does not change despite changes in shape or arrangement, is a key characteristic of the concrete operational stage.

E. Use of symbolic play is more characteristic of the preoperational stage, where children engage in imaginative play rather than concrete operations.

Correct Answer is B

Explanation

A. A stool fat content analysis can suggest malabsorption issues but does not specifically confirm cystic fibrosis.

B. The sweat chloride test measures the amount of chloride in the sweat, with elevated levels confirming a diagnosis of cystic fibrosis.

C. Pulmonary function tests assess lung function but are not definitive for diagnosing cystic fibrosis.

D. A sputum culture can identify respiratory infections but is not specific for cystic fibrosis diagnosis.

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