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
Hypercyanotic spells, also known as “tet spells,” are typically associated with Tetralogy of Fallot, a congenital heart defect. The child in this scenario has congenital mitral stenosis, not Tetralogy of Fallot, making hypercyanotic spells less likely.
Choice B rationale
A murmur is a sound made by turbulent blood flow within the heart. While the child may have a murmur due to congenital mitral stenosis, it is not a direct risk associated with the exacerbation of heart failure. The primary concern here is the risk of digitalis toxicity due to the administration of furosemide.
Choice C rationale
Digitalis toxicity is a significant risk for this child. Furosemide, a diuretic, can cause electrolyte imbalances, particularly hypokalemia, which increases the risk of digitalis toxicity. Symptoms of digitalis toxicity include nausea, vomiting, dizziness, and arrhythmias.
Choice D rationale
Dependent rubor is a reddish-blue discoloration of the extremities, typically associated with peripheral arterial disease. It is not directly related to heart failure or the administration of furosemide.
Choice E rationale
Fever is not a typical complication of heart failure or the administration of furosemide. It is more commonly associated with infections or inflammatory conditions.
Choice F rationale
Carditis, or inflammation of the heart, is not a direct risk associated with the exacerbation of heart failure or the administration of furosemide. The primary concern remains digitalis toxicity.
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.