A nurse takes all of these actions when caring for a 13-year-old who just returned from a cardiac catheterization. Which action is incorrect and requires further discussion?
Replacing the dressing if bleeding is noted.
Positioning the child in a flat-lying position.
Monitoring the pulses distal to the site.
Checking the vital signs every 15 minutes.
The Correct Answer is B
Choice A rationale:
Replacing the dressing if bleeding is noted is appropriate as it helps maintain a clean and sterile site post-catheterization.
Choice B rationale:
Positioning the child in a flat-lying position immediately after cardiac catheterization is incorrect. The child should be placed in a specific position, such as semi-Fowler's, to avoid complications and promote comfort.
Choice C rationale:
Monitoring the pulses distal to the site is essential to assess circulation and potential complications after the procedure.
Choice D rationale:
Checking the vital signs every 15 minutes is appropriate post-catheterization to detect any hemodynamic changes or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The child's preference for macaroni and cheese is unrelated to the diagnosis of bilateral otitis media. This choice does not provide insight into the child's ear condition.
Choice B rationale:
This statement is most likely related to the patient's diagnosis of bilateral otitis media. Falling asleep with a bottle of juice can lead to prolonged exposure of the teeth to sugar, increasing the risk of dental caries, which is commonly associated with ear infections.
Choice C rationale:
The child's behavior of pulling off his hat when outdoors does not offer information about the ear infection and its diagnosis.
Choice D rationale:
The child's refusal to wear shoes indoors is unrelated to the diagnosis of bilateral otitis media. It does not provide relevant information about the ear condition or its management.
Correct Answer is C
Explanation
Choice A rationale:
Allowing a pacifier is appropriate and unrelated to the procedure.
Choice B rationale:
Feeding before the procedure helps prevent dehydration and maintains the infant's well-being.
Choice C rationale:
Bathing immediately after the procedure can introduce infection risk through the catheterization site. Waiting a day is advisable.
Choice D rationale:
Counting wet diapers helps monitor hydration post-procedure; it's a valid concern. In each case, the correct choices were determined by logical reasoning and adherence to medical guidelines. It's important for healthcare providers to educate patients and caregivers to ensure the best outcomes for patients' health and well-being.
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