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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A rationale:
The varicella vaccine is not contraindicated solely based on Down Syndrome. It is important for these children to receive immunizations due to potential increased susceptibility to infections.
Choice B rationale:
A 6-month-old developmentally appropriate infant should receive the varicella vaccine according to the recommended schedule. There is no contraindication for this population.
Choice C rationale:
The varicella vaccine might be contraindicated for a child with autism due to concerns about adverse reactions, as these children might have sensitivities to certain vaccine components.
Choice D rationale:
The varicella vaccine should be contraindicated for a 10-year-old with acquired immune deficiency syndrome (AIDS) due to their compromised immune system. Live vaccines like varicella are usually avoided in immunocompromised individuals.
Choice E rationale:
A 12-year-old child with an arm fracture can still receive the varicella vaccine as it is not contraindicated based solely on this condition.
Correct Answer is D
Explanation
Choice A rationale:
Wet diapers are a sign of hydration, not necessarily nutrition sufficiency.
Choice B rationale:
Introducing solids too early can lead to various issues; it's not linked to sleep improvement.
Choice C rationale:
Cow's milk isn't suitable for a newborn's consumption due to the potential for allergies and digestive issues.
Choice D rationale:
This choice accurately reflects hunger cues in a newborn, demonstrating an understanding of proper feeding.
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