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. "I will increase my food intake before I exercise.": This indicates understanding, as additional carbohydrates may be needed before physical activity to prevent exercise-induced hypoglycemia. Adolescents with type 1 diabetes must learn to balance insulin, food intake, and activity.
B. "As long as I take my insulin, I can eat whatever I want.": Insulin helps manage blood glucose, but dietary choices still matter. Consuming high-sugar or high-fat foods can lead to poor glycemic control, even with insulin administration.
C. "As I get older, my sugar levels will automatically decrease.": Blood glucose levels do not automatically improve with age. Diabetes management remains essential throughout life and often requires adjustments during puberty due to hormonal changes.
D. "The blood pressure medicine I'm taking will help to keep my insulin level low.": Antihypertensives do not regulate insulin levels. Insulin therapy must be managed separately, and medications for blood pressure address cardiovascular risk, not glycemic control.
Correct Answer is B
Explanation
A. Airborne precautions are not required for gentamicin administration, as this medication does not pose a risk of airborne transmission. Gentamicin is an antibiotic, and precautions depend on the infection being treated, not the medication itself.
B. Maintaining strict intake and output is essential when administering gentamicin because it can be nephrotoxic. Monitoring fluid balance helps detect early signs of kidney impairment, allowing timely intervention to prevent further damage.
C. Constipation is not a common adverse effect of gentamicin; gastrointestinal symptoms are more often nausea or vomiting. Monitoring bowel function is important but less critical than kidney function with this medication.
D. Encouraging bed rest is not a standard nursing action specifically related to gentamicin administration. Mobility should be maintained as tolerated to prevent complications like thrombosis unless contraindicated by the patient’s condition.
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