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 B
Explanation
Choice A rationale
Chest pain and dyspnea are concerning symptoms but are not the most immediate manifestations to report in a client undergoing radiation therapy for brain cancer. These symptoms could be related to other conditions and require further evaluation.
Choice B rationale
Seizures are the most immediate manifestation to report because they indicate increased intracranial pressure or other neurological complications related to brain cancer and radiation therapy. Seizures require prompt medical intervention to prevent further complications.
Choice C rationale
Hematuria is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Choice D rationale
Swelling of the extremities is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Correct Answer is B
Explanation
Choice A rationale
Doubling the dose of warfarin if a dose is missed is incorrect because it can lead to an increased risk of bleeding. Warfarin is an anticoagulant, and maintaining a consistent blood level is crucial to avoid complications. Doubling the dose can cause the blood to become too thin, leading to severe bleeding events.
Choice B rationale
Using an electric razor while on warfarin is correct because it helps prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor reduces the chance of nicks and cuts that can occur with a traditional razor.
Choice C rationale
Increasing fiber intake to reduce constipation is incorrect because warfarin does not typically cause constipation. Fiber intake is generally recommended for overall digestive health, but it is not specifically related to warfarin use.
Choice D rationale
Mild nosebleeds are not common during initial treatment with warfarin. Nosebleeds can indicate that the blood is too thin, which is a sign of over-anticoagulation and requires medical attention.