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 SA node sending an electrical signal greater than 100/min describes sinus tachycardia, not atrial fibrillation. In atrial fibrillation, the issue is not with the SA node but with the atria’s chaotic electrical activity.
Choice B rationale
An early electrical signal occurring before the expected SA node signal describes a premature atrial contraction (PAC), not atrial fibrillation. PACs are isolated events, whereas atrial fibrillation involves sustained irregular electrical activity.
Choice C rationale
Slow electrical transmission through the AV node describes a heart block, not atrial fibrillation. In atrial fibrillation, the problem is with the atria’s rapid and irregular electrical signals, not the AV node’s conduction speed.
Choice D rationale
Atrial fibrillation is characterized by rapid, chaotic, and irregular electrical signals in the atria. This leads to an irregular and often rapid heart rate, causing symptoms like dizziness and palpitations. .
Correct Answer is D
Explanation
Choice A rationale
Urinary output is an important postoperative assessment, but it is not the highest priority for a client who has undergone a thoracotomy and lobectomy. Monitoring urinary output helps assess kidney function and fluid balance, but it does not directly address the respiratory status, which is critical in this case. The primary concern after thoracotomy and lobectomy is ensuring adequate oxygenation and ventilation, as the surgery directly impacts the lungs and respiratory function.
Choice B rationale
Pain level is a significant postoperative assessment, as effective pain management is crucial for recovery. However, it is not the highest priority in this scenario. While managing pain is essential to prevent complications such as atelectasis (collapse of part of the lung) due to shallow breathing, the immediate focus should be on assessing and maintaining adequate respiratory function. Pain management can be addressed once the client’s respiratory status is stabilized.
Choice C rationale
Chest tube drainage is a critical postoperative assessment for clients who have undergone thoracotomy and lobectomy. Monitoring chest tube output helps detect complications such as bleeding or pneumothorax (air in the pleural space). However, it is not the highest priority compared to arterial blood gases assessment. While chest tube drainage provides valuable information about the client’s condition, arterial blood gases assessment directly measures the client’s oxygenation and ventilation status, which is paramount in the immediate postoperative period.
Choice D rationale
Arterial blood gases (ABG) assessment is the highest priority for a client who is postoperative following a thoracotomy and lobectomy. ABG analysis provides crucial information about the client’s oxygenation, ventilation, and acid-base balance. This assessment helps detect hypoxemia (low blood oxygen levels), hypercapnia (elevated carbon dioxide levels), and respiratory acidosis, which are critical concerns after lung surgery. Ensuring adequate oxygenation and ventilation is the top priority to prevent respiratory complications and support the client’s recovery.