A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization.
The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure.
Which of the following should the nurse plan to include in the discharge teaching?
Apply pressure dressing four hours after discharge.
Call the provider if the patient’s leg feels cool to touch compared to the left extremity.
Administer acetaminophen or ibuprofen oral solution if needed for pain.
Maintain a clear liquid diet for 24 hours after discharge.
The Correct Answer is C
Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.
Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.
Correct Answer is A
Explanation
Choice A rationale
Acute rheumatic fever is a complication that can occur after an infection with group A streptococcus, which causes strep throat and sometimes scarlet fever. The most common symptoms of rheumatic fever include fever, painful and tender joints, pain in the chest, fatigue, fast heart rate, palpitations, and multiple-joint inflammation. Therefore, asking if the child has had a sore throat recently is relevant as it could indicate a recent strep throat infection, which is a common precursor to acute rheumatic fever.
Choice B rationale
While injuries can lead to various health complications, they are not directly related to the development of acute rheumatic fever. Acute rheumatic fever is primarily caused by an overreaction of the body’s immune system to a strep throat or scarlet fever infection.
Therefore, recent injuries would not typically be a relevant factor in a suspected case of acute rheumatic fever.
Choice C rationale
Acute rheumatic fever is not a congenital condition, meaning it is not present from birth. It develops as a complication of strep throat or scarlet fever. Therefore, asking if the child was born with a cardiac defect would not typically be relevant in a suspected case of acute rheumatic fever.
Choice D rationale
While aspirin is often used in the treatment of rheumatic fever to reduce inflammation and pain, it is not a cause of the condition. Therefore, asking if the child has been given aspirin in the past 2 weeks would not typically be relevant in a suspected case of acute rheumatic fever.
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