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
Instructing to slowly exhale with pursed lips is a breathing technique but not the first action to take before the procedure.
Choice B rationale
Assessing pulse and respirations is important but not the first action to take before the procedure.
Choice C rationale
Assessing characteristics of her sputum is important but not the first action to take before the procedure.
Choice D rationale
Auscultating lung fields is the first action to take to assess the client’s current respiratory status and determine the effectiveness of the upcoming procedure. .
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.