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 C
Explanation
Choice A rationale:
Waiting to discuss the surgery until the child asks specific questions might lead to increased anxiety as the child may be apprehensive about the surgery but unable to express their concerns.
Choice B rationale:
Setting aside an hour a day to talk about the child's feelings concerning the surgery can be overwhelming for a 5-year-old, potentially increasing anxiety and making the procedure seem more daunting.
Choice C rationale:
Reading the child a story about children of similar age who go to the hospital for surgery provides a developmentally appropriate approach. It helps the child understand the process through relatable characters, reducing fear and uncertainty about the upcoming experience.
Choice D rationale:
Having the child visit a family whose preschool child has just been discharged from the hospital might expose the child to unfamiliar situations, possibly leading to more confusion and anxiety.
Correct Answer is B
Explanation
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
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