A nurse is providing postoperative care for a child following an arterial cardiac catheterization. Which of the following actions should the nurse take?
Remove the child's pressure dressing after the first 4 hours.
Maintain the child's NPO status for 4 to 6 hours.
Keep the affected extremity straight for at least 6 hours.
Monitor output using an indwelling urinary catheter for the first 24 hours.
The Correct Answer is C
Choice A reason: Removing the child's pressure dressing after the first 4 hours is not recommended as it may increase the risk of bleeding. The pressure dressing is typically kept in place longer to ensure hemostasis.
Choice B reason: Maintaining the child's NPO status for 4 to 6 hours post-procedure is a standard practice to prevent nausea and vomiting while anesthesia wears off, but it is not the most critical action in this context.
Choice C reason: Keeping the affected extremity straight for at least 6 hours is essential to prevent bleeding from the catheterization site. This is a critical postoperative care step following arterial cardiac catheterization.
Choice D reason: Monitoring output using an indwelling urinary catheter for the first 24 hours is important for assessing kidney function and fluid balance but is not the immediate priority post-cardiac catheterization.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
Correct Answer is A
Explanation
Choice A reason: Avoiding raw fruits and vegetables is crucial for a child with neutropenia because these foods can harbor bacteria that may cause infection in a child with a weakened immune system. It is important to minimize the risk of infection by providing a diet that includes cooked or thoroughly washed fruits and vegetables.
Choice B reason: Administering vaccines prior to discharge may not be appropriate for a child with neutropenia, as live vaccines are contraindicated due to the risk of infection. Vaccination should be deferred until the child's immune system has recovered.
Choice C reason: Obtaining the child's rectal temperature once daily is not recommended for a child with neutropenia due to the risk of introducing bacteria into the body, which can lead to infection.
Choice D reason: Bathing the child every other day does not directly relate to the care of neutropenia. While personal hygiene is important, the frequency of bathing should be based on the child's needs and condition.
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