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 C
Explanation
Choice A rationale:
Administering a bolus of intravenous (IV) fluids might be necessary for severe dehydration, but in mild dehydration, oral rehydration is preferred as it avoids potential complications associated with IV fluids.
Choice B rationale:
Offering clear fluids, popsicles, and gelatin is appropriate, but this choice does not specifically address rehydration, which is the primary concern in mild dehydration.
Choice C rationale:
Offering oral rehydration solution (ORS) in small, frequent amounts is the most appropriate intervention for mild dehydration secondary to diarrhea. ORS contains the right balance of electrolytes and fluids to rehydrate without overwhelming the gastrointestinal tract.
Choice D rationale:
Keeping the child on a strict BRAT diet (bananas, rice, applesauce, toast) is an outdated approach. While BRAT foods can be tolerated during mild illness, they lack the necessary electrolytes and fluids to effectively rehydrate.
Correct Answer is B
Explanation
Choice A rationale:
Failing to regularly wash their hands after eating may contribute to the transmission of various infections, but it's not specifically related to pinworms.
Choice B rationale:
Failing to adequately wipe themselves after toileting can lead to the transfer of pinworm eggs from the anal area to the fingers and under the nails. This behavior increases the risk of ingesting the eggs through hand-to-mouth contact, which can perpetuate the pinworm infection cycle.
Choice C rationale:
Sharing clothing with friends might facilitate the transmission of certain infections like lice or fungal infections, but it's not a common mode of transmission for pinworms.
Choice D rationale:
Engaging in frequent hand-to-mouth activity might increase the risk of ingesting pinworm eggs, but the eggs are more likely to be present on the hands due to inadequate wiping after toileting.
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