A nurse is providing postoperative care for a child following an arterial cardiac catheterization. Which of the following actions should the nurse take?
Remove the child's pressure dressing after the first 4 hours.
Maintain the child's NPO status for 4 to 6 hours.
Keep the affected extremity straight for at least 6 hours.
Monitor output using an indwelling urinary catheter for the first 24 hours.
The Correct Answer is C
Choice A reason: Removing the child's pressure dressing after the first 4 hours is not recommended as it may increase the risk of bleeding. The pressure dressing is typically kept in place longer to ensure hemostasis.
Choice B reason: Maintaining the child's NPO status for 4 to 6 hours post-procedure is a standard practice to prevent nausea and vomiting while anesthesia wears off, but it is not the most critical action in this context.
Choice C reason: Keeping the affected extremity straight for at least 6 hours is essential to prevent bleeding from the catheterization site. This is a critical postoperative care step following arterial cardiac catheterization.
Choice D reason: Monitoring output using an indwelling urinary catheter for the first 24 hours is important for assessing kidney function and fluid balance but is not the immediate priority post-cardiac catheterization.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Soaking hairbrushes in boiling water is a good practice for decontamination, but it is not specific to the treatment of impetigo, which is a bacterial skin infection.
Choice B reason: Acyclovir is an antiviral medication and would not be effective against impetigo, which is caused by bacteria, typically Staphylococcus aureus or Streptococcus pyogenes.
Choice C reason: Sealing soft toys in a plastic bag for 14 days may help to prevent the spread of infection, but it is not a direct treatment for impetigo itself.
Choice D reason: Applying a bactericidal ointment, such as mupirocin, is a standard treatment for impetigo. It helps to eliminate the bacteria causing the infection and promotes healing of the skin lesions.
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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