When a 9-year-old child feels nauseous and vomits after a cardiac catheterization, which is the priority nursing intervention?
Apply a cool cloth to the child's forehead.
Offer the child sips of orange juice.
Apply pressure to the cardiac catheterization site.
Monitor the cardiac catheterization site for bleeding.
The Correct Answer is D
Choice D rationale:
Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.
Choice A rationale:
Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.
Choice B rationale:
Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.
Choice C rationale:
Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Correct Answer is B
Explanation
Choice A rationale:
Administering pancreatic enzymes between meals may not provide the necessary digestive support when food is introduced to the gastrointestinal tract. These enzymes are meant to aid in digestion, so administering them between meals might not be as effective as when taken in conjunction with food.
Choice B rationale:
Administering pancreatic enzymes before meals is the most appropriate time because it helps replace the missing enzymes in patients with cystic fibrosis. These enzymes aid in breaking down food and absorbing nutrients, compensating for the deficient pancreatic function. By giving the enzymes before meals, the body has the necessary support to digest the incoming food.
Choice C rationale:
While administering enzymes during meals might seem logical, it's actually less effective. The enzymes need time to mix with the ingested food before it enters the small intestine, where digestion primarily occurs.
Choice D rationale:
Administering pancreatic enzymes after meals wouldn't be as effective because the enzymes need to be present when food enters the stomach and begins the digestive process.
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