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." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
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Related Questions
Correct Answer is A
Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
Correct Answer is C
Explanation
A. "Ask the child to hold their breath while the IV catheter is placed." Holding breath can increase anxiety and is not necessary for IV insertion. Instead, distraction techniques (e.g., deep breathing, counting) are more effective.
B. "Explain the procedure to the child in detail." Preschoolers have limited understanding of medical procedures. Instead, use simple, age-appropriate language and possibly a demonstration with a toy.
C. "Apply vapocoolant spray before the IV insertion." Vapocoolant spray or topical anesthetics (e.g., EMLA cream) help reduce pain and anxiety associated with IV insertion.
D. "Place the IV catheter on the dominant arm." IV placement is typically based on vein accessibility, not dominance. However, placing it on the non-dominant arm may be preferable to avoid interference with activities.
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