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 C
Explanation
Choice A reason: Talking to a toddler about the meaning of death may not be appropriate or helpful, as they may not fully understand the concept. It's important to provide comfort rather than potentially causing confusion or distress.
Choice B reason: While encouraging friends to visit can provide social support, it may not always be feasible or in the best interest of the child's health, especially if the child is very ill or immunocompromised.
Choice C reason: Staying close to the child provides emotional support and comfort, which is crucial during this difficult time. Physical presence and affection can be very reassuring for both the child and the parents.
Choice D reason: Changing the child's schedule every day can be disruptive and may cause additional stress. Consistency and routine can provide a sense of security and stability for a child who is terminally ill.
Correct Answer is A
Explanation
Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.
Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.
Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.
Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.
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