Page 1070 - Saunders Comprehensive Review For NCLEX-RN

arterial obstruction.
4. Monitor vital signs frequently, usually every 15
minutes 4 times, every half-hour 4 times, and then
every hour 4 times.
5. Assess the pressure dressing for intactness and signs
of hemorrhage.
6. Check the bed sheets under the extremity for blood,
which indicates bleeding from the entry site.
7. If bleeding is present, apply continuous, direct
pressure at the cardiac catheter entry site and report it
immediately.
8. Immobilize the affected extremity in a flat position for
at least 4 to 6 hours for venous entry site and 6 to 8
hours for arterial entry site as prescribed.
9. Hydrate the child via the oral or intravenous route or
both routes as prescribed.
10. Administer acetaminophen or ibuprofen for pain or
discomfort as prescribed.
11. Prepare the parents and child, if appropriate, for
surgery.
D. Discharge teaching for the child and parents

1. Remove the dressing on the day after the procedure
and cover it with a bandage for 2 or 3 days as
prescribed.
2. Keep the site clean and dry.
3. Avoid tub baths for 2 to 3 days.
4. Observe for redness, edema, drainage, bleeding, and
fever, and report any of these signs immediately.
5. Avoid strenuous activity, if applicable.
6. The child may return to school, if appropriate.
7. Provide a diet as tolerated.
8. Administer acetaminophen or ibuprofen for pain,
discomfort, or fever.
9. Keep follow-up appointment with the pediatrician.
IX. Cardiac Surgery
A. Postoperative interventions
1. Monitor vital signs frequently, especially temperature,
and notify the surgeon if fever occurs.
2. Monitor for signs of sepsis such as fever, chills,
diaphoresis, lethargy, and altered levels of
consciousness.
3. Maintain strict aseptic technique.
4. Monitor lines, tubes, or catheters that are in place, and
monitor for signs and symptoms of infection.
5. Assess for signs of discomfort such as irritability,
restlessness, changes in heart rate, respiratory rate,
and blood pressure.

1070