When a 9-year-old child feels nauseous and vomits after a cardiac catheterization, which is the priority nursing intervention?
Apply a cool cloth to the child's forehead.
Offer the child sips of orange juice.
Apply pressure to the cardiac catheterization site.
Monitor the cardiac catheterization site for bleeding.
The Correct Answer is D
Choice D rationale:
Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.
Choice A rationale:
Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.
Choice B rationale:
Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.
Choice C rationale:
Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Threat to body image is not the primary concern for an 8-year-old patient undergoing diagnostic testing for seizures. Seizures are primarily neurological in nature.
Choice B rationale:
Fear of bodily injury might be a concern, but for an 8-year-old patient undergoing diagnostic testing for seizures, the more immediate concern would likely be related to their social interactions and acceptance among peers.
Choice C rationale:
Loss of peer acceptance is the most likely psychological concern for an 8-year-old patient during diagnostic testing. Children at this age are highly conscious of fitting in with their peers, and a medical condition might make them worry about being different.
Choice D rationale:
Separation from parents could be a concern for younger children, but 8-year-olds are generally more independent and less likely to experience extreme separation anxiety.
Correct Answer is C
Explanation
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
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