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
An abdominal aortic aneurysm (AAA) is most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal aorta. The suprarenal aorta is the section of the aorta above the renal arteries, and while aneurysms can occur there, it is not the most common location for AAAs. Therefore, this statement is incorrect.
Choice B rationale
An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition. This statement is correct and should be included in the teaching.
Choice C rationale
An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm. This statement is incorrect as it misrepresents the pathophysiology of AAAs.
Choice D rationale
Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture. This statement is incorrect.
Correct Answer is D
Explanation
Choice A rationale
A room that is within view of the nurses’ station is not suitable for a client with active tuberculosis. This placement does not provide the necessary isolation to prevent the spread of the infection to other patients and staff. Tuberculosis is an airborne disease, and the client needs to be in a room that minimizes the risk of airborne transmission.
Choice B rationale
A room with another nonsurgical client is also inappropriate for a client with active tuberculosis. Placing the client with another patient increases the risk of transmission of the infection. Tuberculosis requires strict airborne precautions, and the client should be in a private room with appropriate ventilation.
Choice C rationale
A room in the ICU is not necessary unless the client requires intensive care for other reasons. The primary concern for a client with active tuberculosis is to prevent the spread of the infection, which can be effectively managed in a regular medical-surgical unit with proper isolation measures.
Choice D rationale
A room with air exhaust directly to the outdoor environment is the correct choice. This type of room, often referred to as a negative pressure room, ensures that air from the room does not flow to other parts of the facility, thereby preventing the spread of infectious airborne particles. This setup is essential for managing clients with active tuberculosis.