The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate the need for further teaching?
"I should avoid tub baths but may shower."
"I have to stay on strict bed rest for 3 days."
"I may attend school but should avoid exercise for several days."
"I should remove the pressure dressing the day after the procedure.".
The Correct Answer is B
The correct answer is choice B: "I have to stay on strict bed rest for 3 days."
Choice A rationale:
The statement "I should avoid tub baths but may shower" is correct. After a cardiac catheterization, the patient needs to keep the insertion site clean and dry to prevent infection. Showering is allowed, but tub baths should be avoided to minimize the risk of introducing water into the insertion site.
Choice B rationale:
The statement "I have to stay on strict bed rest for 3 days" is incorrect. Bed rest is not typically required after a cardiac catheterization. While the patient might need to lie flat for a few hours after the procedure to prevent bleeding and ensure hemostasis, strict bed rest for three days is unnecessary and could lead to complications like deep vein thrombosis (DVT) or deconditioning.
Choice C rationale:
The statement "I may attend school but should avoid exercise for several days" is correct. Attending school is generally acceptable after a cardiac catheterization, but exercise should be limited for several days to allow the insertion site to heal and to prevent complications like bleeding or hematoma formation.
Choice D rationale:
The statement "I should remove the pressure dressing the day after the procedure" is correct. Pressure dressings are typically removed by healthcare professionals after a specified period, which is usually around 24 hours after the procedure. Removing the dressing on their own the day after the procedure could lead to disruption of the wound and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. They may lie to meet expectations set by others that they have been unable to attain.
Choice A rationale:
Lying resulting from the inability to distinguish between fact and fantasy is more characteristic of younger children and might not be as applicable to the 8 to 10-year-old age group.
Choice B rationale:
While cheating during games might be a behavior observed in children, it doesn't specifically address the characteristic of dishonesty outlined in the question for this age group.
Choice C rationale:
Children aged 8 to 10 years may lie to meet expectations set by others that they have been unable to attain. This is a manifestation of social pressure and the desire to avoid disappointing others or facing consequences for not meeting perceived expectations.
Choice D rationale:
Stealing due to a limited sense of property rights might apply more to younger children who are still developing their understanding of ownership and boundaries.
Correct Answer is C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
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