A nurse is planning care for an infant following a cardiac catheterization. Which of the following interventions should the nurse include in the plan?
Assess vital signs every 4 hours.
Monitor the color of the affected extremity.
Maintain NPO status for 8 hours.
Keep the affected extremity flexed.
The Correct Answer is B
Choice A reason: Assessing vital signs every 4 hours is important, but it is not specific to the care of an infant post-cardiac catheterization. Vital signs should be monitored according to the infant's condition and hospital policy.
Choice B reason: Monitoring the color of the affected extremity is crucial after cardiac catheterization to ensure there is no compromise in blood flow, which could indicate a vascular injury or thrombosis at the catheterization site.
Choice C reason: Maintaining NPO (nothing by mouth) status for 8 hours may be necessary before the procedure, but post-catheterization care typically includes gradual reintroduction of fluids and then food as tolerated.
Choice D reason: Keeping the affected extremity flexed is not recommended post-cardiac catheterization. The limb should be kept straight to avoid bending at the catheterization site, which could lead to bleeding or clot formation.
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Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.
Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.
Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.
Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.
Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.
Correct Answer is C
Explanation
Choice A reason: Assessing the child's pulse and respirations can indicate pain through physiological changes, but these signs can be influenced by other factors and may not provide an accurate measure of pain intensity.
Choice B reason: Observing the child's facial expressions can give some indication of pain, but it is subjective and may not accurately reflect the child's pain experience, especially if the child is trying to hide their discomfort.
Choice C reason: Asking the child to use a FACES rating scale allows the child to actively participate in communicating their pain level. This method is age-appropriate and provides a visual way for children to express the intensity of their pain, making it a reliable assessment technique.
Choice D reason: Monitoring the child's involuntary movements can provide clues about pain, but like facial expressions, they are subjective and may not accurately quantify the child's pain level.
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