A nurse is assessing a client immediately following a cardiac catheterization.

The nurse should notify the provider for which of the following findings?

Choice A reason:

"You might experience altered taste sensations" is the correct statement. When providing teaching to a client about to undergo external radiation therapy for cancer, the nurse should include information about potential side effects and what to expect during the treatment. One common side effect of radiation therapy, especially when the treatment is focused on or near the head and neck region, is altered taste sensations. Radiation can affect the taste buds and lead to changes in how foods taste.

Choice B reason:

"Use rubbing alcohol to remove the ink markings. “The statement is incorrect. The ink markings made on the client's skin are used as reference points for the radiation therapy treatment. It is essential not to remove these markings, as they are crucial for accurate positioning during each treatment session. The nurse should instruct the client not to tamper with the markings, and the radiation therapy team will remove them when they are no longer needed.

Choice C reason:

"Wear a binder over the radiation site." The statement is incorrect. Wearing a binder over the radiation site is not a standard practice during external radiation therapy. The client should be instructed to follow the specific guidelines provided by the radiation therapy team regarding clothing and positioning during treatments. The use of binders or other tight clothing over the treatment area may not be recommended, as it can cause discomfort or interfere with the delivery of radiation.

Choice D reason

"Wash your skin thoroughly with a washcloth after each treatment." Is incorrect statement. During radiation therapy, the skin in the treatment area can become sensitive. It is essential for the client to follow the specific instructions provided by the radiation therapy team regarding skin care. Generally, the client should avoid using harsh soaps or scrubbing the skin vigorously. Instead, they should gently cleanse the area with a mild soap or as directed by their healthcare providers.

The correct answer is choice A. Limit oral feedings to 30 min in length.

This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.

Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.

Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.

Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.