Nursing interventions for the child after a cardiac catheterization when they first return to the unit include all of the answers below except:
Assess the affected extremity for temperature and color.
Manage hydration with IV fluids until able to tolerate oral fluids.
Check pulses above the catheterization site for equality and symmetry.
Monitor vital signs frequently.
The Correct Answer is B
Choice A reason: This is a correct statement, as assessing the affected extremity for temperature and color can help detect any signs of vascular injury or thrombosis after the cardiac catheterization. The extremity should be warm and pink, indicating adequate blood flow. If the extremity is cold, pale, or cyanotic, it may indicate ischemia or occlusion¹.
Choice B reason: This is not a correct statement, as managing hydration with IV fluids until able to tolerate oral fluids is not a necessary intervention after the cardiac catheterization. The child may be able to resume oral fluids as soon as they are awake and alert, unless there are contraindications such as nausea or vomiting. IV fluids may be given to prevent dehydration or hypotension, but they should be monitored carefully to avoid fluid overload or pulmonary edema¹².
Choice C reason: This is a correct statement, as checking pulses above the catheterization site for equality and symmetry can help detect any signs of arterial injury or spasm after the cardiac catheterization. The pulses should be strong and equal on both sides, indicating normal blood flow. If the pulses are weak, absent, or unequal, it may indicate arterial occlusion or narrowing¹.
Choice D reason: This is a correct statement, as monitoring vital signs frequently can help detect any signs of bleeding, infection, or cardiac complications after the cardiac catheterization. The vital signs should be stable and within normal limits, indicating normal hemodynamic status. If the vital signs are abnormal, such as hypotension, tachycardia, fever, or dysrhythmia, it may indicate hemorrhage, sepsis, or cardiac tamponade¹².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct cause, as varicella is a viral infection that causes a blister-like rash all over the body, not just in the diaper area. Varicella also causes fever, headache, and malaise.
Choice B reason: This is the correct cause, as Candida albicans is a type of fungus that can cause diaper rash, especially after antibiotic use. Antibiotics can disrupt the normal flora of the skin and allow the fungus to grow. Candida albicans causes red, inflamed skin with small, raised bumps around the edges.
Choice C reason: This is not the correct cause, as impetigo is a bacterial infection that causes honey-colored crusts on the skin, usually around the mouth and nose. Impetigo is contagious and can spread to other parts of the body or other people.
Choice D reason: This is not the correct cause, as bacterial infection is too vague and nonspecific. Bacterial infection can cause different types of skin rashes, depending on the type and location of the bacteria. Bacterial infection may also cause other symptoms, such as fever, pus, or swelling.
Correct Answer is B
Explanation
Choice A reason: Cardiac arrhythmia is an abnormal heart rhythm that can affect the heart's ability to pump blood. However, it is not a direct consequence of a ventricular septal defect (VSD), which is a hole in the wall between the lower chambers of the heart¹.
Choice B reason: Decreased cardiac output is the amount of blood pumped by the heart per minute. It can be reduced by a VSD, as the blood can flow back from the left ventricle to the right ventricle through the hole, instead of being pumped to the body. This can cause the infant to have cool extremities, thready pulses, and low urine output, as the tissues are not receiving enough oxygen and nutrients².
Choice C reason: Increased stroke volume is the amount of blood pumped by the heart per beat. It can be increased by a VSD, as the left ventricle has to work harder to compensate for the blood loss through the hole. However, this does not explain the infant's symptoms, as the stroke volume may not be enough to maintain a normal cardiac output².
Choice D reason: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. It can be caused by a VSD, as the oxygen-rich blood from the left ventricle can mix with the oxygen-poor blood from the right ventricle through the hole, and then be pumped to the body. However, this is more likely to occur in large VSDs or in infants with other heart defects that cause right-to-left shunting of blood³.
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