a 3 year old child is scheduled for a cardiac catheterization what is the priority nursing care after this procedure
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Nursing Elites

HESI LPN

Pediatric HESI 2024

1. After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?

Correct answer: B

Rationale: After a cardiac catheterization, the priority nursing care for a 3-year-old child is monitoring the site for bleeding. This is essential to promptly identify and address any signs of bleeding or hematoma formation, which are potential complications of the procedure. Encouraging early ambulation may be beneficial post-procedure but ensuring site integrity takes precedence. Restricting fluids until blood pressure stabilization is not a standard post-catheterization practice, as adequate hydration is crucial for recovery. Comparing the blood pressure of both lower extremities is not a priority immediate nursing action after a cardiac catheterization in a pediatric patient.

2. What would a healthcare professional expect to find when assessing the skin of a child with cellulitis?

Correct answer: B

Rationale: Cellulitis is characterized by warmth at the site of skin disruption, indicating an infection. The correct answer is choice B. Choice A, 'Red, raised hair follicles,' is more indicative of folliculitis rather than cellulitis. Choice C, 'Papules progressing to vesicles,' is more characteristic of conditions like chickenpox, not cellulitis. Choice D, 'Honey-colored exudate,' is typical of wound infections with bacteria like Staphylococcus aureus, not cellulitis.

3. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Assessing for signs of dehydration is crucial in infants with hypertrophic pyloric stenosis (HPS) because they are at high risk due to frequent vomiting. Dehydration can lead to serious complications if not promptly addressed. Choices A, C, and D are not the priority assessments for HPS. While the quality of the cry can provide some information on the infant's distress level, dehydration assessment takes precedence. Coughing up feedings may not be specific to HPS, and characteristics of the stool, although important in general assessments, are not the priority in this situation.

4. A healthcare professional is preparing to administer an oral medication to a 4-year-old child. What is the best approach to gain the child's cooperation?

Correct answer: B

Rationale: Allowing the child to play with a favorite toy while taking the medication is the best approach to gain cooperation. This strategy can help distract and calm the child during the medication administration process. Choice A may not be as effective with a young child who may not fully understand the explanation. Offering a reward (choice C) may reinforce negative behavior and create a dependency on rewards for cooperation. Giving the medication with food (choice D) may not always be appropriate and may not address the cooperation aspect.

5. The nurse is conducting a physical examination of a 9-month-old baby with a flat, discolored area on the skin. The nurse documents this as a:

Correct answer: B

Rationale: A macule is defined as a flat, discolored area on the skin that is different from surrounding tissue due to a change in color. In this case, the baby has a flat, discolored area on the skin, which fits the description of a macule. A papule is a small, raised solid bump, a vesicle is a small fluid-filled blister, and a scale is a flake of skin that is often dry and rough. Therefore, choices A, C, and D do not accurately describe the flat, discolored area on the baby's skin, making them incorrect.

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