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?
Bilateral cool extremities
Blood pressure 102/58 mm Hg
Serum glucose 90 mg/dL
Weak pedal pulse distal to the site
The Correct Answer is D
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.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
B. A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
C. Correct. Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.
D. Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
Correct Answer is ["2.2"]
Explanation
To calculate the dose of ondansetron for a child who is receiving chemotherapy, the nurse needs to use the following formula:
Dose (mL) = (Dose ordered in mg / Dose available in mg) x Volume available in mL
In this case, the dose ordered in mg is 0.15 mg/kg x 29.4 kg, which equals 4.41 mg. The dose available in mg is 4 mg, and the volume available in mL is 2 mL. Therefore, the dose in mL is:
Dose (mL) = (4.41 mg / 4 mg) x 2 mL Dose (mL) = 2.205 mL
The nurse should round the answer to the nearest tenth, so the final answer is 2.2 mL. The nurse should administer 2.2 mL of ondansetron IV to the child who is receiving chemotherapy.
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