A nurse is teaching wound care to parents after cardiac surgery. Which statement is most appropriate?
Lotions and powders are acceptable.
Your child can take a complete bath tomorrow.
Tingling, itching, and numbness are normal sensations at the wound site.
If the sterile adhesive strips over the incision fall off, call the physician.
The Correct Answer is C
Post–cardiac surgery discharge teaching focuses on normal wound healing expectations, infection prevention, and safe home care. Parents should be reassured about findings that are expected and non-dangerous, while being warned about findings that require medical attention.
Rationale for the correct answer:
C. Tingling, itching, and numbness are normal sensations at the wound site commonly occur as nerves heal and regenerate following surgery. Mild itching is also associated with normal tissue repair. Teaching this helps reduce parental anxiety and prevents unnecessary calls or clinic visits. Parents should still be instructed to report increasing pain, redness, swelling, drainage, or fever, which are not normal.
Rationale for incorrect answers:
A. Lotions and powders can trap moisture and bacteria, increasing the risk of infection. Incisions should be kept clean and dry unless otherwise prescribed.
B. Full immersion (baths, swimming) is usually restricted until the incision is well healed. Sponge baths are typically recommended initially to avoid soaking the incision.
D. Sterile adhesive strips (Steri-Strips®) are designed to fall off on their own as healing occurs. Parents should be taught not to pull them off, but falling off naturally does not require notifying the provider.
Test-taking strategy:
- Choose options that normalize expected postoperative findings rather than those that create unnecessary restrictions or anxiety.
- Look for answers that support healing physiology and safe home management.
Take home points
- Mild itching, tingling, and numbness are expected after cardiac surgery.
- Keep incisions clean, dry, and free of lotions or powders.
- Avoid full baths until cleared by the provider.
- Sterile adhesive strips falling off naturally is normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Cardiac tamponade is a life-threatening postoperative complication caused by fluid accumulation in the pericardial sac, which compresses the heart and impairs ventricular filling, leading to reduced cardiac output.
Rationale for the correct answer:
B. Muffled heart sounds: In cardiac tamponade, fluid around the heart dampens the transmission of heart sounds, making them sound distant or muffled. This finding strongly suggests pericardial fluid compressing the heart, requiring immediate intervention.
Rationale for incorrect answers:
A. Hypertension: Cardiac tamponade leads to decreased cardiac output, which typically causes hypotension, not hypertension.
C. Widened pulse pressures: Tamponade causes a narrowed pulse pressure due to reduced stroke volume. Widened pulse pressure is more consistent with conditions like patent ductus arteriosus.
D. Increased chest tube drainage: Tamponade is more likely when chest tube drainage decreases or suddenly stops, allowing fluid to accumulate in the pericardial space. Increased drainage is generally a protective sign, indicating fluid is being removed.
Test-taking strategy:
- Think “pressure on the heart = quiet heart.”
- After cardiac surgery, muffled heart sounds + distress should immediately raise concern for cardiac tamponade.
- Remember the Beck’s triad:
- Muffled heart sounds
- Hypotension
- Jugular venous distention (harder to see in young children, but still relevant physiologically)
Take home points
- Muffled heart sounds are a hallmark sign of cardiac tamponade.
- Tamponade results in impaired filling with eventual decreased cardiac output.
- In post–cardiac surgery children, tamponade is a medical emergency requiring rapid recognition and intervention
Correct Answer is C
Explanation
Post–cardiac surgery care in children focuses on gradual recovery, energy conservation, and prevention of complications. Activity guidance must be realistic, flexible, and developmentally appropriate, rather than overly restrictive or unsafe.
Rationale for the correct answer:
C. Encourage a balance of rest and exercise: After cardiac surgery, children fatigue easily due to healing tissues, altered circulation, and reduced endurance. A balance of rest and activity allows the child to gradually rebuild strength and stamina without overexertion. This guidance supports safe recovery, promotes normal growth and development, and helps parents monitor tolerance (e.g., stopping activity if the child becomes tired, short of breath, or uncomfortable).
Rationale for incorrect answers:
A. There are no exercise limitations: This is unsafe and incorrect. Children typically have temporary activity restrictions following cardiac surgery to protect the sternum, incision, and heart. Overexertion can increase the risk of complications.
B. The child may resume school in 3 days: Return to school is not standardized and depends on the child’s recovery, endurance, and provider recommendations. Most children require more than a few days before resuming full school activities.
D. Climbing and contact sports are restricted for 1 week: Contact sports and climbing are usually restricted for several weeks, not just one. The sternum and surgical site require adequate healing to prevent injury or wound disruption.
Test-taking strategy:
- Avoid answers that are absolute or overly specific when recovery timelines vary.
- Choose responses that emphasize individualized care and gradual progression, which are commonly correct in pediatric postoperative questions.
Take home points
- Children recovering from cardiac surgery need gradual activity progression.
- Fatigue is expected; rest periods are essential.
- High-risk activities (contact sports, climbing) are restricted for weeks, not days.
- Balanced, flexible guidance is safer than rigid timelines.
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