Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.)

Correct Answer: A

Rationale: In the context of pediatric patients undergoing cardiac catheterization, the correct nursing intervention of allowing ambulation as tolerated is crucial for promoting circulation, preventing complications such as blood clots, and aiding in the child's overall recovery. Encouraging movement also helps in preventing complications related to prolonged immobility, such as muscle stiffness and decreased lung function. Monitoring vital signs every 2 hours is not typically a standard nursing intervention post-cardiac catheterization in pediatric patients unless there are specific indications or complications arise. While assessing the affected extremity for temperature and color is important in some situations, it is not a routine nursing intervention following cardiac catheterization unless there are specific concerns such as signs of infection or impaired circulation. Checking pulses above the catheterization site for equality and symmetry is not a primary nursing intervention post-cardiac catheterization in pediatric patients. While monitoring pulses is essential in assessing circulation, focusing on the site above the catheterization may not always be directly related to the immediate post-procedure care in all cases. In an educational context, it is important for nursing students to understand the rationale behind each nursing intervention post-cardiac catheterization in pediatric patients. This includes recognizing the significance of early mobilization, appropriate monitoring based on individual patient needs, and targeted assessments to ensure optimal recovery and prevent complications. By prioritizing evidence-based interventions, nurses can provide safe and effective care to pediatric patients undergoing cardiac procedures.

Correct Answer: B

Rationale: To administer an IM injection of 2.4 million units of penicillin G, the nurse should first reconstitute the penicillin powder with sterile water as per the instructions. The vial contains 5,000,000 units of the powder and when diluted with 8 mL of sterile water, the resulting concentration would be:

Correct Answer: D

Rationale: One beef cube typically contains about 800mg of sodium, and 8oz of tomato juice contains approximately 480mg of sodium. Therefore, to provide a total of 1,600mg of sodium daily, the nurse could supplement the patient's diet with one beef cube (800mg sodium) and 12oz of tomato juice (720mg sodium). This combination would effectively provide the required 1,600mg of sodium per day for the patient with abnormal sodium losses.

Correct Answer: C

Rationale: Hypokalemia is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes. Potassium is an essential electrolyte for muscle function, including maintaining muscle tone and supporting proper nerve conduction for reflexes. When potassium levels are low, it can lead to muscle weakness, decreased muscle tone, and reduced deep tendon reflexes. With severe diarrhea, potassium is often lost along with fluids, leading to a potential electrolyte imbalance such as hypokalemia. Additionally, hypokalemia can cause cardiac arrhythmias, muscle cramps, and fatigue, further supporting the presence of this electrolyte imbalance in Ms. CC.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) New set of tracheostomy tubes and Oxygen tank. This is the most appropriate choice because in the event of a dislodged tracheostomy tube, immediate replacement of the tubes is crucial to maintain the airway patency and ensure adequate oxygenation for the patient. The oxygen tank is also necessary to provide supplemental oxygen to the patient during this emergency situation. Option B) Theophylline and Epinephrine are medications that are not relevant to the immediate management of a dislodged tracheostomy tube. These medications are not used to address airway emergencies. Option C) Obturator and Kelly clamp are also not the correct choices in this situation. While an obturator can be used to guide the tracheostomy tube during insertion, and a Kelly clamp can be used for securing the tracheostomy tube in place, neither of these items address the immediate need for replacing the dislodged tracheostomy tubes. Option D) Sterile saline dressing is used for wound care and is not directly related to the management of a dislodged tracheostomy tube. In an educational context, it is important for healthcare providers, especially nurses, to be well-versed in emergency situations such as a dislodged tracheostomy tube. Understanding the appropriate equipment and interventions necessary in such scenarios is crucial for providing safe and effective patient care. Regular training and simulation exercises can help nurses develop the skills and confidence needed to respond effectively in emergencies like this.