A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
Offer the child clear liquids for the first 24 hours.
Assist the child to take a tub bath for the first 3 days.
Give the child acetaminophen for discomfort.
Keep the child home for 1 week.
The Correct Answer is C
Choice A reason: Offering the child clear liquids for the first 24 hours is not necessary, as the child can resume a normal diet after the procedure. Clear liquids are only recommended for the first few hours after the procedure to prevent nausea and vomiting.
Choice B reason: Assisting the child to take a tub bath for the first 3 days is not advised, as it can increase the risk of infection and bleeding at the catheter insertion site. The child should avoid tub baths, swimming, and soaking the site until it is completely healed, which may take up to a week.
Choice C reason: Giving the child acetaminophen for discomfort is appropriate, as it can relieve the pain and soreness at the catheter insertion site. The child should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as they can increase the risk of bleeding.
Choice D reason: Keeping the child home for 1 week is not required, as the child can resume normal activities within a few days after the procedure. The child should avoid strenuous activities, such as running, jumping, and biking, for at least 24 hours after the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the length of the straps of the Pavlik harness by themselves, as this may affect the position and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not breastfeed the infant while wearing the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to remove the harness before breastfeeding the infant, and to reapply it after feeding.
Choice C reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should place the diaper under the straps of the harness, as this prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.
Choice D reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Balancing the scale to 0 prior to use is a correct action for the nurse to take. This ensures that the scale is accurate and does not include any extra weight from the scale itself or any objects on it.
Choice B reason: Using a stadiometer to measure the infant is not a correct action for the nurse to take. A stadiometer is a device that measures the height of a standing person. It is not suitable for measuring the length of an infant who cannot stand. The nurse should use a measuring board or a tape measure to measure the infant's length.
Choice C reason: Placing a disposable covering on the scale is a correct action for the nurse to take. This prevents the transmission of germs or dirt from the scale to the infant or vice versa. It also protects the scale from any urine or stool that the infant may produce during the weighing.
Choice D reason: Weighing the infant in a diaper is not a correct action for the nurse to take. A diaper can add extra weight to the infant's measurement and affect the accuracy of the result. The nurse should weigh the infant without any clothing or diaper.
Choice E reason: Measuring the infant from crown of the head to the heels of feet is a correct action for the nurse to take. This is the standard method of measuring the length of an infant. The nurse should place the infant on a flat surface, align the head with the top of the measuring board or tape measure, and extend the legs fully. The nurse should then read the measurement at the bottom of the infant's feet.
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