A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure.
Which of the following findings should the nurse report to the provider?
Weak pedal pulse distal to the site
Blood pressure 102/58mm Hg
Bilateral cool extremities
Serum glucose 90mg/dL
The Correct Answer is A
Choice A rationale
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
Choice B rationale
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
Choice C rationale
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
Choice D rationale
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
The correct answer is choice a. Discourage the child from coughing.
Choice A rationale:
Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.
Choice B rationale:
Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.
Choice C rationale:
Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.
Choice D rationale:
Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.
Correct Answer is B
Explanation
Choice A rationale
Osteomyelitis is an infection of the bone, typically caused by bacteria. While it can occur as a complication of a fracture, it is not the most immediate concern within the first 24 hours after injury.
Choice B rationale
Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow. It can develop within hours of a severe injury like a fracture. Therefore, it is crucial to monitor for signs of compartment syndrome, such as severe pain, paleness, numbness, or decreased strength, in the first 24 hours after a fracture.
Choice C rationale
Volkmann ischemic contracture is a condition that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. However, this condition is not typically seen within the first 24 hours after injury.
Choice D rationale
Renal calculi, or kidney stones, are hard deposits made of minerals and salts that form inside your kidneys. They are not a complication that would arise within the first 24 hours after a fracture.
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