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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Potential changes in employee benefits are important to address, but job security is a more immediate concern for employees facing agency restructuring.
B. Changes in job descriptions may occur as part of agency restructuring, but job security is typically a more pressing concern for employees.
C. Employees' job security is the most important concern to address during agency restructuring.
Employees may feel anxious about the possibility of layoffs or job loss, so providing reassurance and clear communication about job security is essential for maintaining morale and reducing
stress.
D. New management's expectations may be relevant, but they are secondary to employees' concerns about their job security during agency restructuring. Once job security is assured, addressing new management's expectations can be addressed.
Correct Answer is B
Explanation
A. Monitoring for changes in stool color is important because itraconazole can rarely cause liver toxicity, which may manifest as changes in stool color (e.g., clay-colored stools). This statement demonstrates the client's understanding of the need for monitoring for potential adverse effects.
B. Taking itraconazole with antacids is incorrect because antacids can reduce the absorption of itraconazole. This statement requires correction by the nurse as it could potentially decrease the effectiveness of the medication.
C. Drinking grapefruit juice can increase the effects of itraconazole by inhibiting its metabolism, leading to higher blood levels of the medication. Therefore, this statement is incorrect and requires correction.
D. Reporting any difficulty with breathing is important as itraconazole can rarely cause severe allergic reactions or respiratory side effects. This statement demonstrates the client's
understanding of the need to report any concerning symptoms.
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