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 C
Explanation
Choice A rationale
Hypercyanotic spells, also known as “tet spells,” are typically associated with Tetralogy of Fallot, a congenital heart defect. The child in this scenario has congenital mitral stenosis, not Tetralogy of Fallot, making hypercyanotic spells less likely.
Choice B rationale
A murmur is a sound made by turbulent blood flow within the heart. While the child may have a murmur due to congenital mitral stenosis, it is not a direct risk associated with the exacerbation of heart failure. The primary concern here is the risk of digitalis toxicity due to the administration of furosemide.
Choice C rationale
Digitalis toxicity is a significant risk for this child. Furosemide, a diuretic, can cause electrolyte imbalances, particularly hypokalemia, which increases the risk of digitalis toxicity. Symptoms of digitalis toxicity include nausea, vomiting, dizziness, and arrhythmias.
Choice D rationale
Dependent rubor is a reddish-blue discoloration of the extremities, typically associated with peripheral arterial disease. It is not directly related to heart failure or the administration of furosemide.
Choice E rationale
Fever is not a typical complication of heart failure or the administration of furosemide. It is more commonly associated with infections or inflammatory conditions.
Choice F rationale
Carditis, or inflammation of the heart, is not a direct risk associated with the exacerbation of heart failure or the administration of furosemide. The primary concern remains digitalis toxicity.
Correct Answer is A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is caused by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the coagulation cascade, leading to the formation of small blood clots throughout the bloodstream. This process consumes clotting factors and platelets, increasing the risk of severe bleeding.
Choice B rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is typically a secondary condition resulting from other underlying issues such as sepsis, trauma, or malignancy. Vitamin K deficiency can lead to bleeding disorders, but it is not the cause of DIC13.
Choice C rationale
DIC is characterized by a decreased platelet count, not an elevated one. The consumption of platelets and clotting factors in the formation of microthrombi leads to thrombocytopenia and an increased risk of bleeding.
Choice D rationale
DIC is not controllable with lifelong heparin usage. While heparin may be used in certain cases to manage DIC, it is not a lifelong treatment. The management of DIC focuses on treating the underlying cause and supporting the patient through the acute phase of the disorder.