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
While chest pain can occur after pacemaker insertion, it is not the primary concern immediately following the procedure. The nurse should monitor for more critical complications such as arrhythmias, which can indicate pacemaker malfunction or lead displacement.
Choice B rationale
Infection is a potential complication after pacemaker insertion, but it typically develops over a longer period. Immediate monitoring should focus on acute complications such as arrhythmias.
Choice C rationale
Bleeding is a concern after any surgical procedure, including pacemaker insertion. However, the primary immediate concern is monitoring for arrhythmias, which can indicate issues with the pacemaker’s function.
Choice D rationale
Arrhythmias are the primary concern immediately following pacemaker insertion. The nurse should monitor the client for any irregular heart rhythms, which can indicate pacemaker malfunction or lead displacement. Prompt identification and management of arrhythmias are crucial to ensure the pacemaker is functioning correctly.