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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

Explanation

A. Solitary play is more characteristic of earlier stages of development, such as infancy and early childhood. School-age children benefit more from social interactions.

B. While academic achievements are important, focusing solely on individual success does not support the social skills that are essential for this developmental stage.

C. Encouraging participation in team sports promotes social interaction, teamwork, and a sense of belonging, which are crucial for developing competence and self-esteem during this stage.

D. Promoting dependence on parents goes against the developmental task of this age group, which is to foster independence and decision-making skills.

Correct Answer is A

Explanation

A. A child with varicella (chickenpox) should return to school only after all the blisters have crusted over, indicating that the infectious stage has passed and they are no longer contagious.

B. Receiving the varicella vaccine does not apply to children who already have the infection; vaccination is preventive, not a treatment for those already infected.

C. Completing one week of antiviral medication is not a sufficient criterion for returning to school, as the child may still be contagious until all lesions are crusted.

D. Returning to school as soon as the rash appears is not safe, as the child is highly contagious during the initial rash stage and until all lesions have crusted.

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