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 B
Explanation
A. Doubling the dose if a dose is missed can increase the risk of bleeding and is not recommended for warfarin. Instead, the client should take the missed dose as soon as remembered unless it's almost time for the next dose.
B. Using an electric razor is recommended to minimize the risk of cuts and bleeding, which is particularly important for clients on anticoagulants like warfarin.
C. While increasing fiber intake can be beneficial for overall health, it is not specifically necessary for addressing constipation related to warfarin therapy.
D. While mild nosebleeds may occur, they are not typically common during initial treatment. Clients should be informed to report any unusual or severe bleeding.
Correct Answer is ["C","D","E"]
Explanation
A. Pertussis primarily affects the respiratory tract rather than just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.
C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.
D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.
E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.