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A nurse is caring for an adolescent following a cardiac catheterization.

Exhibits

Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

Apical pulse.

Adolescent's position.

Pulses of right extremity.

Pain.

Pressure dressing.

Respiratory rate.

Blood pressure.

Temperature & appearance of right lower extremity.

Answer and Explanation

Correct Answer : C,E,G,H

Choice A rationale:

The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.

Choice B rationale:

The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.

Choice C rationale:

The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.

Choice D rationale:

The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.

Choice E rationale:

The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.

Choice F rationale:

The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.

Choice G rationale:

The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.

Choice H rationale:

The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.

So, the correct answer is Choice C, E, G, H, after analyzing all choices. .

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Correct Answer is C

Explanation

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

A. Obtain blood cultures x 3. B. Administer antibiotic therapy. C. Obtain an echocardiogram. D. Restrict dental hygiene. E. Perform strenuous exercise regimen twice daily.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.

Choice B rationale:

Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.

Choice C rationale:

Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.

Choice D rationale:

Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.

Choice E rationale:

Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.

So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .

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A nurse is caring for an adolescent following a cardiac catheterization. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

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A nurse is caring for an adolescent following a cardiac catheterization. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

A nurse is caring for an adolescent following a cardiac catheterization.

Exhibits

Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.