A nurse is caring for a 6-month-old who had a cardiac catheterization.

Exhibits

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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.

B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.

C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.

D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.

A. Instructing the client to eat foods that are low in potassium. B. Repeat the dose if the client spits it out. C. Measuring apical pulse rate for 30 seconds before administration. D. Evaluating the client for nausea, vomiting, and anorexia.

Correct Answer is C

Explanation

A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.

B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.

C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.

D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?

Correct Answer is C

Explanation

A nurse is teaching a caregiver of a school-age child about physical activity. Which of the following statements made by the caregiver demonstrates the teaching was effective? (Select All that Apply.)

A nurse is providing teaching to students about physical and psychosocial effects of stress to school-aged children. Which of the following levels of prevention does this demonstrate?

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

The nurse is caring for a nine-year-old client on the pediatric unit. What is the most effective way for the nurse to support this child in achieving Erikson's developmental task of industry versus inferiority?

A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

A nurse is providing care for a group of hospitalized school-aged children. Which of the following clients should the nurse prioritize for further assessment and interventions?