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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.
Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is characterized by high blood pressure that develops after 20 weeks of pregnancy and typically resolves within a few weeks postpartum. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage.
However, Sarah’s condition does not fit this description because her blood pressure has been consistently high since she was 26, not just during pregnancy.
Choice B rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. Given Sarah’s history of consistent high blood pressure since age 26 and her recent seizure at 32 weeks’ gestation, this choice fits her condition.
Choice C rationale
Gestational hypertension refers to high blood pressure that begins during pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. However, Sarah’s high blood pressure did not begin during pregnancy, making this choice incorrect.
Choice D rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. HELLP Syndrome (Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels) is a serious health condition that can affect pregnant women3. However, Sarah’s symptoms do not indicate HELLP Syndrome, making this choice incorrect.
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