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?
Give the child acetaminophen for discomfort.
Keep the child home for 1 week.
Assist the child to take a tub bath for the first 3 days.
Offer the child clear liquids for the first 24 hours.
The Correct Answer is A
Choice A rationale
Giving the child acetaminophen for discomfort is appropriate as it helps manage pain without interfering with the healing process.
Choice B rationale
Keeping the child home for 1 week is not necessary unless there are specific complications or instructions from the healthcare provider.
Choice C rationale
Assisting the child to take a tub bath for the first 3 days is not recommended as it may increase the risk of infection at the catheter insertion site.
Choice D rationale
Offering the child clear liquids for the first 24 hours is not necessary unless there are specific dietary restrictions from the healthcare provider.
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Correct Answer is D
Explanation
Choice A rationale
The client has an increased risk for bleeding. Cisplatin is a chemotherapy drug that can cause myelosuppression, leading to a decrease in platelets (thrombocytopenia). However, the client’s platelet count is 170,000/mm³, which is within the normal range (150,000-450,000/mm³). Therefore, the client does not have an increased risk for bleeding based on the current CBC results.
Choice B rationale
The client should receive an erythropoiesis stimulating agent. Cisplatin can cause anemia due to myelosuppression, which would be indicated by a low hemoglobin (Hgb) and hematocrit (Hct). However, the client’s Hgb is 12.1 g/dL and Hct is 36.5%, both of which are within normal limits (Hgb: 12-16 g/dL for females, Hct: 36-48% for females). Therefore, there is no immediate need for an erythropoiesis stimulating agent based on the current CBC results.
Choice C rationale
The client should receive a diet with increased protein. While a high-protein diet can be beneficial for cancer patients to help maintain muscle mass and support recovery, the CBC results do not indicate a specific need for increased protein intake. The client’s albumin level is 4.5 g/dL, which is within the normal range (3.5-5.0 g/dL), indicating adequate protein status.
Choice D rationale
The client has an increased risk of infection. Cisplatin can cause neutropenia, a condition characterized by a low white blood cell (WBC) count, which increases the risk of infection. The client’s WBC count is 1,400/mm³, which is significantly below the normal range (4,000- 11,000/mm³). This indicates severe neutropenia, putting the client at a high risk for infections. Therefore, it is crucial for the nurse to consider infection prevention measures for this client.
Correct Answer is D
Explanation
Choice A rationale
A room that is within view of the nurses’ station is not suitable for a client with active tuberculosis. This placement does not provide the necessary isolation to prevent the spread of the infection to other patients and staff. Tuberculosis is an airborne disease, and the client needs to be in a room that minimizes the risk of airborne transmission.
Choice B rationale
A room with another nonsurgical client is also inappropriate for a client with active tuberculosis. Placing the client with another patient increases the risk of transmission of the infection. Tuberculosis requires strict airborne precautions, and the client should be in a private room with appropriate ventilation.
Choice C rationale
A room in the ICU is not necessary unless the client requires intensive care for other reasons. The primary concern for a client with active tuberculosis is to prevent the spread of the infection, which can be effectively managed in a regular medical-surgical unit with proper isolation measures.
Choice D rationale
A room with air exhaust directly to the outdoor environment is the correct choice. This type of room, often referred to as a negative pressure room, ensures that air from the room does not flow to other parts of the facility, thereby preventing the spread of infectious airborne particles. This setup is essential for managing clients with active tuberculosis.