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NurseDive Free Nursing Practice Question
A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?
A. Bilateral cool extremities
Bilateral cool extremities can be common after a cardiac catheterization due to transient vasoconstriction but is not necessarily an immediate concern if perfusion remains adequate.
B. Blood pressure 102/58 mm Hg
Blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not require reporting.
C. Serum glucose 90 mg/dL
Serum glucose of 90 mg/dL is within normal limits for a toddler and does not indicate a complication.
D. Weak pedal pulse distal to the site
Weak pedal pulse distal to the site should be reported because it may indicate arterial occlusion or compromised circulation following the procedure. While pulses may initially be weak due to swelling, they should not be absent or significantly diminished over time.
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Full Explanation
A. Bilateral cool extremities can be common after a cardiac catheterization due to transient vasoconstriction but is not necessarily an immediate concern if perfusion remains adequate.
B. Blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not require reporting.
C. Serum glucose of 90 mg/dL is within normal limits for a toddler and does not indicate a complication.
D. Weak pedal pulse distal to the site should be reported because it may indicate arterial occlusion or compromised circulation following the procedure. While pulses may initially be weak due to swelling, they should not be absent or significantly diminished over time.
Similar Questions
A nurse is teaching a group of parents about childhood immunizations. The nurse should identify that infants should receive the first dose of which of the following immunizations at 12 months of age?
A. Hepatitis B
The first dose of the Hepatitis B vaccine is typically administered shortly after birth, not at 12 months of age.
B. Varicella
The first dose of the Varicella (chickenpox) vaccine is recommended at 12 months of age.
C. Human papillomavirus
The Human Papillomavirus (HPV) vaccine is not typically started until the preadolescent or adolescent years, typically around ages 11-12.
D. Inactivated polio virus
The first dose of the Inactivated Polio Virus (IPV) vaccine is usually given at 2 months of age, with additional doses at 4 months and 6-18 months.
Full Explanation
A. The first dose of the Hepatitis B vaccine is typically administered shortly after birth, not at 12 months of age.
B. Correct. The first dose of the Varicella (chickenpox) vaccine is recommended at 12 months of age.
C. The Human Papillomavirus (HPV) vaccine is not typically started until the preadolescent or adolescent years, typically around ages 11-12.
D. The first dose of the Inactivated Polio Virus (IPV) vaccine is usually given at 2 months of age, with additional doses at 4 months and 6-18 months.
A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy.
Which of the following actions should the nurse take? (Select all that apply.)
A. Maintain the child in a supine position.
Maintaining the child in a supine position is not recommended after a tonsillectomy.The child should be positioned on their side to prevent aspiration.
B. Provide cranberry juice to the child.
Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. Discourage the child from coughing.
While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administer an analgesic to the child on a scheduled basis.
Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observe the child for frequent swallowing.
Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
Full Explanation
A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.
B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the following actions should the nurse take
A. Apply warm compresses to the affected areas.
Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decrease the child's fluid intake.
Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Administer furosemide IV twice per day.
Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.It is not an appropriate intervention in this situation.
D. Initiate contact precautions.
Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.
Full Explanation
A. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.
D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.