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
Maintaining a semi-Fowler’s position can help improve lung expansion and ease breathing in clients with chronic obstructive pulmonary disease (COPD). However, it does not directly address the issue of mucus congestion and difficulty in expectorating (bringing up) mucus.
While positioning can aid in overall respiratory comfort, it is not the most effective intervention for managing mucus congestion in COPD clients.
Choice B rationale
A low-salt diet is beneficial for overall health and can help manage conditions such as hypertension and heart disease. However, it does not have a direct impact on mucus congestion in clients with COPD. Dietary modifications are important for managing comorbidities, but they do not address the primary concern of mucus clearance in this scenario.
Choice C rationale
Encouraging the client to drink 2 to 3 liters of water daily is an effective intervention for managing mucus congestion in clients with COPD. Adequate hydration helps thin the mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of difficulty in expectorating mucus and can improve respiratory function and comfort.
Choice D rationale
Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation in clients with COPD. However, it does not address the issue of mucus congestion and difficulty in expectorating mucus. While supplemental oxygen is important for managing hypoxemia, it is not the primary intervention for mucus clearance. The focus should be on interventions that help thin and mobilize mucus to alleviate the client’s symptoms.
Correct Answer is B
Explanation
Choice A rationale
Fever. This statement is incorrect. While fever can occur in clients with ITP due to infections, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice B rationale
Ecchymosis. This statement is correct. Ecchymosis, or bruising, is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies. Clients with ITP are prone to bruising and bleeding even with minor trauma.
Choice C rationale
Fatigue. This statement is incorrect. While fatigue can occur in clients with ITP due to anemia or chronic illness, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice D rationale
Elevated WBC. This statement is incorrect. Elevated white blood cell counts are not typically associated with ITP, which primarily affects platelet counts. An elevated WBC may indicate infection or inflammation but is not specific to ITP10111213.