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 B
Explanation
A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.
B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.
D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.
Correct Answer is C
Explanation
A. Providing lab results to the parent without the client's consent violates the client’s right to privacy under HIPAA (Health Insurance Portability and Accountability Act).
B. While the healthcare provider may discuss results, the nurse must first ensure the client has given consent for the parent to receive medical information.
C. Since the client is an adult (22 years old), their medical information is confidential. The nurse can only share information with the parent if the client provides explicit consent.
D. This response is inappropriate and dismissive, potentially damaging the nurse-client relationship. A professional and respectful explanation should be given.
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