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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.

Perform a sterile dressing change 8 hr after the procedure.

B.

Keep the affected extremity straight for 4 hr.

C.

Assess the pulses above the catheterization site.

D.

Maintain NPO status for 24 hr following the procedure.

Answer and Explanation

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. Give the child 3 to 6 oz of orange juice. The child's altered mental status, diaphoresis, and tremors indicate hypoglycemia. The best initial treatment for mild to moderate hypoglycemia is a fast-acting carbohydrate, such as orange juice (3 to 6 oz) to rapidly raise blood glucose levels.
B. Give the child a candy bar. While candy contains sugar, it also contains fat, which slows glucose absorption, delaying the correction of hypoglycemia.
C. Administer glucagon to the vastus lateralis. Glucagon is used for severe hypoglycemia (e.g., unconsciousness or seizures), not for mild to moderate symptoms.
D. Administer D5W intravenous fluids. IV dextrose is used in severe cases where the child is unconscious or unable to take oral glucose. Since this child is conscious, oral treatment is preferred.

Correct Answer is C

Explanation

A. Perform gastric lavage with activated charcoal. Activated charcoal is most effective if given within 1 hour of ingestion. Since the ingestion occurred 4 hours ago, activated charcoal would not be beneficial.
B. Begin hemodialysis within the next 24 hr. Hemodialysis is only used in severe cases of acetaminophen toxicity with liver failure, which is not indicated at this stage.
C. Prepare to give oral N-acetylcysteine. N-acetylcysteine (NAC) is the antidote for acetaminophen overdose and should be administered as soon as possible within 8 to 10 hours after ingestion to prevent liver damage.
D. Send the child home on increased fluid intake. Acetaminophen overdose can cause severe liver toxicity, so treatment in a medical setting is required, not just increased fluids at home.

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