A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?
Keep the affected extremity straight for 4 hr.
Perform a sterile dressing change 8 hr after the procedure.
Maintain NPO status for 24 hr following the procedure.
Assess the pulses above the catheterization site.
The Correct Answer is A
A. Keep the affected extremity straight for 4 hr: Keeping the leg straight helps prevent bleeding and hematoma formation at the catheter insertion site. This is a key nursing intervention after femoral venous cardiac catheterization to promote healing and reduce complications.
B. Perform a sterile dressing change 8 hr after the procedure: The dressing is typically kept intact unless it becomes soiled or saturated. Routine dressing changes within 8 hours are not necessary and could increase the risk of infection at the insertion site.
C. Maintain NPO status for 24 hr following the procedure: Prolonged NPO status is not required after cardiac catheterization. The child can usually resume oral intake once fully awake and stable, with no nausea or vomiting present.
D. Assess the pulses above the catheterization site: Pulse assessment should focus on distal pulses below the catheterization site to ensure adequate circulation. Checking pulses above the site does not provide relevant information about perfusion to the affected extremity.
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Related Questions
Correct Answer is D
Explanation
A. Reschedule the procedure until the client's guardian provides written consent: In most states, adolescents have the legal right to consent to reproductive health services, including contraception. Guardian consent is not required for IUD insertion.
B. Call the adolescent's guardian to obtain verbal consent prior to the procedure: Involving a guardian without the adolescent’s permission breaches confidentiality. Reproductive health decisions are protected for adolescents, and verbal consent from a guardian is unnecessary.
C. Encourage the adolescent to wait to ask questions about the device until after its insertion: It is essential for the adolescent to receive complete education and have all questions answered before the procedure. Informed consent cannot be obtained after the procedure has already been done.
D. Witness the adolescent's signature on the consent form: Adolescents can legally provide consent for contraception. The nurse’s role is to witness the signature, ensuring the adolescent understands the procedure and that the consent is voluntary.
Correct Answer is C
Explanation
A. Oxygen saturation: An oxygen saturation of 95% is within the normal range for a school-age child and acceptable for a client with cystic fibrosis, who may have mild baseline respiratory compromise.
B. WBC count: A WBC count of 9,600/mm³ is within the normal pediatric range (5,000–10,000/mm³). It does not suggest acute infection or bone marrow suppression, so it is not a reportable finding.
C. HbA1c: An HbA1c of 8.5% is significantly elevated above the normal range (4%–5.9%). This indicates poor glycemic control, suggesting cystic fibrosis–related diabetes, a common complication. This requires provider notification for further evaluation and management.
D. Heart rate: A heart rate of 98/min is within the normal range for school-age children (75–118/min). It does not indicate acute distress or cardiac complications, so it does not warrant immediate reporting.
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