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 A
Explanation
Choice A reason: This statement is developmentally appropriate and helps to alleviate the child's anxiety about pain during the procedure. It uses language that a 4-year-old can understand without causing unnecessary fear.
Choice B reason: While it is comforting to know a parent will be close by, this statement is not accurate as parents are typically not present in the operating room during the procedure. It could lead to confusion and distress when the parent is not there.
Choice C reason: This statement is too vague and may not be fully understood by a child. It lacks the reassurance that the child will not feel pain, which is an important aspect to address.
Choice D reason: Although this statement is positive and forward-looking, it does not address the child's immediate concerns about the procedure itself. It is important to reassure the child about what to expect during the surgery.
Correct Answer is B
Explanation
Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.
Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.
Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.
Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.
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