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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. A child whose parents consistently answer questions on their behalf may indicate a lack of autonomy and could be a sign of potential abuse or neglect, as it may suggest the parents are controlling or overly involved.

B. A child who has frequent visitors does not inherently suggest abuse; in fact, it could indicate support and care from family or friends.

C. Frequent use of the call light could indicate a child's need for assistance or comfort but does not directly correlate with abuse.

D. A child with a BMI indicating obesity is not a definitive indicator of abuse; it may relate to dietary habits or lifestyle factors rather than abuse.

Correct Answer is C

Explanation

A. Monitoring lung function and oxygen saturation is important but not the primary purpose of chest physiotherapy.

B. Chest physiotherapy does not primarily focus on pain relief or reducing inflammation; instead, it targets mucus clearance.

C. Chest physiotherapy is primarily performed to enhance lung function by mobilizing and clearing thick mucus from the airways, which is critical in managing cystic fibrosis and preventing infections.

D. While medications can be administered via nebulization, chest physiotherapy itself is not used for direct medication delivery but rather for airway clearance.

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