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 ["A","B","D","E"]
Explanation
A. Physical activity can improve academic performance, as studies show a positive correlation between physical fitness and cognitive function.
B. Engaging in physical activity four days a week is consistent with recommendations for school-age children, promoting overall health and fitness.
C. While light activities are beneficial, it is important for children to engage in moderate to vigorous activities for optimal health, so this statement may not fully reflect effective teaching.
D. Climbing is indeed a beneficial activity that helps strengthen muscles, showing an understanding of how different physical activities contribute to physical development.
E. The statement regarding exercise reducing the risk of diabetes is accurate and reflects an understanding of the long-term health benefits of physical activity.
Correct Answer is B
Explanation
A. Administering IV fluids may be necessary but is not the first priority in managing a suspected airway emergency.
B. Placing the child on droplet precautions is the first action to take to prevent the spread of infection and protect healthcare workers, given the suspected diagnosis of epiglottitis.
C. Initiating IV antibiotics is essential but should follow ensuring that appropriate precautions and assessments are in place.
D. While obtaining an x-ray can confirm the diagnosis, the child's safety and airway management must be prioritized first to avoid potential respiratory distress.