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.
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Related Questions
Correct Answer is C
Explanation
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
Correct Answer is D
Explanation
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.
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