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 B
Explanation
Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.
Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.
Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.
Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.
Correct Answer is B
Explanation
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
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