A nurse takes all of these actions when caring for a 13-year-old who just returned from a cardiac catheterization. Which action is incorrect and requires further discussion?
Replacing the dressing if bleeding is noted.
Positioning the child in a flat-lying position.
Monitoring the pulses distal to the site.
Checking the vital signs every 15 minutes.
The Correct Answer is B
Choice A rationale:
Replacing the dressing if bleeding is noted is appropriate as it helps maintain a clean and sterile site post-catheterization.
Choice B rationale:
Positioning the child in a flat-lying position immediately after cardiac catheterization is incorrect. The child should be placed in a specific position, such as semi-Fowler's, to avoid complications and promote comfort.
Choice C rationale:
Monitoring the pulses distal to the site is essential to assess circulation and potential complications after the procedure.
Choice D rationale:
Checking the vital signs every 15 minutes is appropriate post-catheterization to detect any hemodynamic changes or complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.
Choice B rationale:
Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.
Choice C rationale:
Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.
Choice D rationale:
The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.
Correct Answer is C
Explanation
Urine output 76 mL/24 hours.
Choice A rationale:
BUN (Blood Urea Nitrogen) of 14 mg/dL falls within the normal range (7-20 mg/dL) and is not an immediate concern.
Choice B rationale:
Serum Creatinine of 0.4 mg/dL is also within the normal range (0.2-0.5 mg/dL) and does not warrant immediate action.
Choice C rationale:
Urine output of 76 mL/24 hours is significantly decreased from the expected normal range (1-2 mL/kg/hour), indicating potential kidney dysfunction or dehydration. This requires immediate action to assess the child's hydration status and kidney function.
Choice D rationale:
Hb (Hemoglobin) of 12 g/dL is within the normal range for a 5-year-old child (11.5-15.5 g/dL) and does not necessitate urgent intervention.
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