Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization.

What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Measure the child's height and weight

Document lying, sitting, and standing blood pressures

Locate and mark the pedal pulses

Perform a mini mental exam on the child

Obtain a history of allergic reactions

Determine when the child last ate

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Measuring the child's height and weight is essential to ensure appropriate dosing of medications and to assess the child's growth and development.
B. Documenting lying, sitting, and standing blood pressures can help detect orthostatic hypotension, which may be a concern during or after the procedure.
C. Locating and marking the pedal pulses is important for assessing the vascular status of the lower extremities, especially since the catheterization involves accessing a blood vessel.
D. Performing a mini mental exam on the child is not typically part of the pre-cardiac catheterization assessment for a 3-year-old.
E. Obtaining a history of allergic reactions is crucial to prevent any potential allergic response to medications or materials used during the catheterization.
F. Determining when the child last ate is necessary because the child will need to fast for a certain period before the procedure to reduce the risk of aspiration.

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Correct Answer is D

Explanation

A. Assisting the client to recall everyone possibly exposed since the onset of symptoms is important for contact tracing but is not the most immediate action to take.
B. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for infection control but does not address the immediate need to prevent
potential transmission to others in the clinic setting.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is appropriate for specimen handling but does not address the need for immediate infection control measures for the client and others in the clinic setting.
D. Moving the client to a private room, keeping the door closed, and initiating droplet precautions is the most important action to take to prevent potential transmission of COVID-19 to others in the clinic setting, given the client's symptoms and recent travel history.

A. Ask the client how often episodes of sundowning are experienced. B. Encourage the client to lie as still as possible during the assessment. C. Question the client about the frequency of falls in recent months. D. Assist the client with values clarification about end-of-life care options.

Correct Answer is C

Explanation

A. Asking the client how often episodes of sundowning are experienced is not relevant to a
functional assessment. Sundowning refers to increased confusion and agitation that typically occurs in the late afternoon or evening and is often associated with dementia.
B. Encouraging the client to lie as still as possible during the assessment may not provide accurate information about the client's functional status. It's important for the client to engage in activities that reflect their typical level of functioning.
C. Questioning the client about the frequency of falls in recent months is an essential component of a functional assessment, especially for an older adult being admitted to a rehabilitation facility.
Understanding the history of falls helps identify potential risk factors and informs the development of an appropriate care plan.
D. Assisting the client with values clarification about end-of-life care options is important but not typically part of a functional assessment focused on evaluating the client's physical and cognitive abilities.

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Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Correct Answer is C

Explanation

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Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization.

What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.