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 A
Explanation
Choice A rationale:
Expiratory wheezing is characteristic of asthma exacerbation. It indicates airway constriction and narrowing, leading to difficulty in exhaling and resulting in a high-pitched sound during expiration.
Choice B rationale:
Inspiratory crackle is not typically associated with asthma. Crackles are often heard in conditions involving fluid-filled airways, such as pneumonia.
Choice C rationale:
Expiratory grunting is not a common finding in asthma. Grunting sounds may be present in infants with respiratory distress, indicating the difficulty they experience while exhaling.
Choice D rationale:
Inspiratory stridor is not a usual manifestation of asthma. Stridor is more commonly related to upper airway obstruction, often seen in croup or epiglottitis.
Correct Answer is A
Explanation
Choice A rationale:
Children with nephrotic syndrome are at an increased risk of infection due to loss of immunoglobulins and other immune-related proteins in the urine, along with the use of immunosuppressive medications. The proteinuria associated with nephrotic syndrome leads to hypoalbuminemia and decreased immunity, making the child susceptible to infections, particularly bacterial peritonitis. Preventive measures include proper hand hygiene, maintaining a clean environment, and timely administration of prescribed antibiotics.
Choice B rationale:
Hypertension is not a primary complication of nephrotic syndrome in children. While they may have fluid retention and edema, resulting in increased blood pressure, infection is a more significant concern.
Choice C rationale:
Weight loss is not a typical complication of nephrotic syndrome but rather the opposite. Children with nephrotic syndrome often experience weight gain due to fluid retention and edema.
Choice D rationale:
Hyperkalemia is a possible electrolyte imbalance in nephrotic syndrome, but it is not a primary concern for children with this condition. The loss of protein in the urine can lead to hypoalbuminemia and subsequent edema, but hyperkalemia is not a common initial complication.
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