A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?
Perform a sterile dressing change 8 hr after the procedure.
Keep the affected extremity straight for 4 hr.
Assess the pulses above the catheterization site.
Maintain NPO status for 24 hr following the procedure.
The Correct Answer is B
A. Perform a sterile dressing change 8 hr after the procedure: Dressing changes are typically done only if the dressing becomes wet, soiled, or loose. Routine dressing changes soon after the procedure can increase the risk of bleeding or infection and are generally avoided during the initial recovery period.
B. Keep the affected extremity straight for 4 hr: Keeping the affected leg straight helps prevent bleeding and hematoma formation at the catheter insertion site by minimizing movement and pressure on the femoral vein. This immobilization period is critical to allow proper healing and reduce complications.
C. Assess the pulses above the catheterization site: It is important to assess pulses distal to the insertion site (e.g., in the foot) to monitor for signs of impaired circulation or vascular compromise. Assessing pulses above the site does not provide information about distal blood flow or potential complications.
D. Maintain NPO status for 24 hr following the procedure: NPO status is usually required only for a few hours before the procedure to reduce aspiration risk. After the catheterization, the child is typically allowed to resume oral intake once fully awake and stable, making prolonged NPO unnecessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mild hematuria: Glomerulonephritis commonly causes inflammation of the glomeruli, leading to leakage of red blood cells into the urine. This results in mild hematuria, which is a typical laboratory finding in this condition. The presence of blood in the urine reflects glomerular damage.
B. Absent urine protein: Proteinuria is usually present in glomerulonephritis due to increased glomerular permeability. The absence of urine protein would be unusual and inconsistent with this diagnosis, as protein leakage often occurs alongside hematuria.
C. Hyponatremia: Although hyponatremia can sometimes occur in glomerulonephritis due to fluid retention and dilution, it is not a primary or consistent laboratory finding. Sodium levels may remain normal or fluctuate depending on the severity of the condition and fluid status.
D. Decreased blood potassium: Potassium levels are typically not decreased in glomerulonephritis. In fact, some cases may show normal or elevated potassium levels due to impaired kidney function and reduced excretion, making decreased potassium an unlikely finding.
Correct Answer is B
Explanation
A. Obtain a prescription for lorazepam: Sedation may be used in some cases, but routinely sedating a toddler post-cleft lip and palate repair is not the first-line intervention to prevent incision site trauma.
B. Place the toddler in bilateral elbow restraints: Elbow restraints are commonly used to prevent toddlers from touching or injuring the surgical site after cleft lip and palate repair, protecting the incision during healing.
C. Place the child in a mummy restraint: Mummy restraints restrict the entire body and can increase distress and anxiety; they are generally avoided unless absolutely necessary.
D. Swaddle the toddler in a blanket: Swaddling can provide comfort and limit movement, but it is less effective than elbow restraints at specifically preventing the child from touching the incision site.
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