A nurse is caring for a 6-month-old who had a cardiac catheterization.
Choose words from the choices below to fill in each blank in the following sentence. Which of the following should the nurse plan to include in the discharge teaching?
The nurse should plan to include_____and______ in the discharge instructions for the guardians.
remove pressure dressing four hours after discharge
administer acetaminophen or ibuprofen oral solution if needed for pain
call provider if right leg feels cool to touch in comparison to left leg
maintain clear liquid diet for 24 hr after discharge
tub bath is permitted 24 hr after procedure
Correct Answer : B,C
The nurse should plan to include Target 1: administer acetaminophen or ibuprofen oral solution if needed for pain and Target 2: call provider if right leg feels cool to touch in comparison to left leg in the discharge instructions for the guardians.
Rationale:
- Administer acetaminophen or ibuprofen oral solution if needed for pain: This instruction is important for managing post-procedure discomfort and promoting the child's comfort.
- Call provider if right leg feels cool to touch in comparison to left leg: This is a critical instruction, as it can indicate potential complications like bleeding or thrombosis. Early identification of these issues is essential for timely intervention.
The other options are not appropriate for discharge teaching in this case:
- Remove pressure dressing four hours after discharge: This is typically done in the hospital setting under the supervision of healthcare professionals.
- Maintain clear liquid diet for 24 hr after discharge: A clear liquid diet may not be necessary after discharge, especially if the child is tolerating oral intake well.
- Tub bath is permitted 24 hr after procedure: While bathing is generally allowed after the procedure, specific instructions regarding water temperature and avoiding submerging the incision site should be provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Holding breath for 10 seconds after inhaling the medication allows for better absorption of the medication in the lungs, indicating understanding of proper inhaler technique.
B. Taking a quick inhalation is incorrect; the client should take a slow, deep breath to ensure the medication reaches the lungs effectively.
C. Waiting 10 minutes between inhalations is not necessary unless specifically instructed; usually, a second puff can be taken after 1-2 minutes if needed.
D. The client should exhale before inhaling the medication, not while it is being released; exhaling first clears the lungs for a more effective inhalation.
Correct Answer is D
Explanation
A. The ASO titer does not measure therapeutic levels of aminoglycosides; this response is incorrect.
B. The ASO titer is not a direct diagnostic test for rheumatic fever but indicates a recent infection with streptococcal bacteria, which can lead to rheumatic fever.
C. The test does not confirm immunity but rather measures antibodies against streptolysin O, indicating recent infection.
D. An elevated ASO titer confirms that the child had a recent streptococcal infection, which is important in diagnosing rheumatic fever.
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