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A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?

A.

Keep the affected extremity straight for 4 hr.

B.

Perform a sterile dressing change 8 hr after the procedure.

C.

Maintain NPO status for 24 hr following the procedure.

D.

Assess the pulses above the catheterization site.

Answer and Explanation

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. Encourage use of a digital gaming device: Bright screens and sensory stimulation can worsen discomfort in a child with bacterial meningitis, as these clients are often sensitive to light and noise. Rest in a quiet, dim environment is more appropriate.

B. Avoid raising the head of the child's bed: Elevating the head of the bed to 30 degrees helps reduce intracranial pressure and promotes venous drainage. Avoiding elevation could worsen symptoms and increase complications.

C. Place the child on seizure precautions: Children with bacterial meningitis are at increased risk for seizures due to inflammation and irritation of the meninges. Seizure precautions, such as padded side rails and having emergency equipment available, are essential.

D. Maintain contact precautions for 24 hr after the start of antibiotics: Bacterial meningitis requires droplet precautions, not contact precautions, for at least 24 hours after antibiotics are initiated. Using the wrong type of isolation would not prevent transmission effectively.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationale:

• Weight-bearing ability on the affected leg: The adolescent was able to ambulate in the hall twice with good tolerance, which suggests improved mobility despite persistent tenderness. This indicates that pain and function are gradually improving.

• Temperature: The fever decreased from 38.8°C on Day 1 to 37.6°C on Day 2, showing resolution of the systemic response to infection. This suggests the antibiotic therapy is beginning to take effect.

• WBC count: The count rose from 14,000/mm³ to 15,000/mm³ in 24 hours, which reflects a persistent or worsening inflammatory and infectious process. This indicates the infection may not yet be under control.

• Wound assessment: The indurated area on the calf decreased in size from 6 x 6 cm on Day 1 to 5 x 5 cm on Day 2. A decrease in the size of the inflamed area indicates that the cellulitis is responding to treatment and resolving.

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