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 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.
Correct Answer is B
Explanation
A. Indicate on a stuffed animal where the procedure will be performed: This approach is more appropriate for preschool-aged children, who learn best through play and concrete objects. School-age children benefit more from factual, age-appropriate explanations.
B. Use simple diagrams to explain the procedure: School-age children can understand basic anatomy and processes. Simple diagrams provide visual reinforcement, reduce anxiety, and help the child grasp what will happen during surgery.
C. Discuss the benefits of the procedure: While explaining benefits is important, focusing only on outcomes without addressing the child’s need for concrete understanding may not fully reduce preoperative anxiety.
D. Provide teaching immediately before the procedure: Teaching should occur in advance to give the child time to process the information, ask questions, and mentally prepare. Immediate pre-op teaching is too rushed for effective learning.
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