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 D
Explanation
A. Applying scented baby powder can irritate the sensitive vaginal area and exacerbate vulvovaginitis symptoms, increasing the risk of allergic reactions and discomfort. Fragrance-free and gentle hygiene measures are preferred to avoid further irritation.
B. Wearing feminine deodorant pads is discouraged because these products often contain fragrances and chemicals that can cause irritation or allergic reactions, worsening vulvovaginitis symptoms. They also do not address the underlying inflammation or infection.
C. Nylon underwear is non-breathable and can trap moisture, creating a warm, damp environment that promotes bacterial and yeast growth, worsening vulvovaginitis. Cotton underwear is recommended as it allows better air circulation and keeps the area dry.
D. Applying a warm, moist compress helps soothe irritation, reduce inflammation, and relieve discomfort associated with vulvovaginitis. This method promotes healing and provides symptomatic relief without introducing irritants.
Correct Answer is D
Explanation
A. Observe abdominal movement to determine the respiratory rate: While observing abdominal movement can help count respirations, in adolescents, chest movement should also be assessed since diaphragmatic breathing is less dominant than in infants.
B. Auscultate the abdomen for at least 1 min if bowel sounds are absent: Bowel sounds should be assessed for a full minute before concluding they are absent; this is standard practice, but it is not a unique action specific to adolescent assessment.
C. Use the FACES scale to assess pain: The FACES pain scale is designed primarily for younger children (typically ages 3 to 8); adolescents generally respond better to numeric or descriptive pain scales.
D. Have the child bend forward at the waist and check for asymmetry of the scapula: This is the recommended screening method for scoliosis, which commonly develops during adolescence; assessing scapular asymmetry during forward bending is appropriate and important for this age group.
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