A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
Offer the child clear liquids for the first 24 hours.
Assist the child to take a tub bath for the first 3 days.
Give the child acetaminophen for discomfort.
Keep the child home for 1 week.
The Correct Answer is C
Choice A reason: Offering the child clear liquids for the first 24 hours is not necessary, as the child can resume a normal diet after the procedure. Clear liquids are only recommended for the first few hours after the procedure to prevent nausea and vomiting.
Choice B reason: Assisting the child to take a tub bath for the first 3 days is not advised, as it can increase the risk of infection and bleeding at the catheter insertion site. The child should avoid tub baths, swimming, and soaking the site until it is completely healed, which may take up to a week.
Choice C reason: Giving the child acetaminophen for discomfort is appropriate, as it can relieve the pain and soreness at the catheter insertion site. The child should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as they can increase the risk of bleeding.
Choice D reason: Keeping the child home for 1 week is not required, as the child can resume normal activities within a few days after the procedure. The child should avoid strenuous activities, such as running, jumping, and biking, for at least 24 hours after the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the length of the straps of the Pavlik harness by themselves, as this may affect the position and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not breastfeed the infant while wearing the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to remove the harness before breastfeeding the infant, and to reapply it after feeding.
Choice C reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should place the diaper under the straps of the harness, as this prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.
Choice D reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.
Correct Answer is B
Explanation
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a child, depending on their age. It does not indicate respiratory distress or asthma exacerbation.
Choice B reason: Wheezes in the lower lobes are a sign of airway obstruction and inflammation due to asthma. They indicate that the child may need additional medication or intervention to relieve their symptoms. The nurse should report this finding to the provider.
Choice C reason: An oxygen saturation of 95% is within the normal range for a child. It does not indicate hypoxia or impaired gas exchange due to asthma.
Choice D reason: A peak expiratory flow rate of 80% of personal best is considered a green zone result, meaning that the child's asthma is well controlled. It does not indicate a need for change in the child's asthma action plan.
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