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 B

Explanation

A. Ask the client to take short, rapid breaths: This can increase respiratory rate and may exacerbate the client's shortness of breath.
B. Instruct the client in pursed lip breathing: Pursed lip breathing can help improve gas exchange and reduce dyspnea by slowing down the client's respiratory rate and increasing oxygenation.
C. Increase oxygen to three L/minute: Increasing oxygen without assessing the client's oxygen saturation may lead to oxygen toxicity and is not indicated without further assessment.
D. Have the client breathe into a paper bag: This intervention is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It is typically used for clients experiencing hyperventilation.

A. A Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

A. Initiating teaching for client care after discharge is not within the scope of practice for a practical nurse (PN). Teaching, particularly initial or complex teaching, is a responsibility of the registered nurse (RN) because it requires assessment, planning, and evaluation of the client’s understanding.

B. Evaluating and updating plans of care is a responsibility of the RN. This activity requires critical thinking and clinical judgment to assess client progress and make adjustments to care plans, which are outside the PN’s scope of practice.

C. Performing the initial sterile wound care for surgical clients should be done by the RN. The initial wound care requires assessment of the wound’s condition, which is a task that involves critical thinking and is beyond the PN’s scope.

D. Validating prescribed intravenous flow rates is an appropriate task for the PN. This task is within their scope of practice as it involves verifying that the IV is running as prescribed but does not require the higher-level assessment and critical thinking skills reserved for the RN.

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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

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is D

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.