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 C
Explanation
A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.
B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.
C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.
D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.
Correct Answer is D
Explanation
A. Visualizing the epiglottis with a tongue depressor is contraindicated in suspected epiglottitis due to the risk of triggering airway obstruction.
B. Transporting the child to radiology for a throat x-ray is not a priority and can delay necessary interventions.
C. Obtaining a throat culture is not appropriate in this situation, as airway compromise can occur quickly, and immediate management is crucial.
D. Placing the child in an upright position helps ease breathing and can alleviate distress, which is vital for a child with suspected epiglottitis.