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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 A

Explanation

A. Avoiding triggers that cause an asthma attack is crucial in managing asthma effectively and should be emphasized in education.

B. Cromolyn sodium is a preventive medication and should be taken regularly, not just at the first sign of difficulty; immediate relief medications are preferred during an attack.

C. The peak expiratory flow meter should be used daily to monitor asthma control, rather than just once a week.

D. It is generally not necessary for the child to stop playing sports; many children with asthma can participate in activities like basketball as long as their condition is well-managed.

Correct Answer is C

Explanation

A. Encouraging the adolescent to spend more time alone may reinforce their withdrawal and does not promote social interaction or engagement.

B. Assigning the adolescent as a leader may increase anxiety and exacerbate their withdrawal rather than encourage socialization.

C. One-on-one counseling can provide a safe space for the adolescent to express feelings and explore the reasons for their withdrawal, which is a supportive and therapeutic intervention.

D. Focusing solely on academic achievements may lead to further isolation and does not address the need for social skills development and peer interaction.

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