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Exhibits

The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Give lactated Ringers IV at 66 mL/hr while NPO

Vital signs every 4 hours

Place the child on a continuous cardiopulmonary monitor

Admit to the pediatric floor for observation

NPO

Point of care blood glucose

Check pedal pulses every 4 hours

Answer and Explanation

Correct Answer : A,F

A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. "I am happy that you are getting better and will be able to go home."
This response focuses on the client’s progress and avoids engaging with their polarized views. It provides positive reinforcement and shifts the focus toward recovery.

B. "Tomorrow I will talk to that nurse about how you were treated last night."
This could escalate the situation and may inadvertently validate the client's idealization or devaluation of others, without fully understanding the dynamics.

C. "I am glad you like me. Which nurse was acting aloof to you?"
This response reinforces the client’s idealization of the current nurse, which could perpetuate dichotomous thinking.

D. "What did the night nurse do that makes you think the nurse is aloof?"
This invites the client to focus on negative perceptions of the night nurse, potentially escalating their emotional instability.

A. Encourage the client to participate in group activities. B. Schedule a daily conference with the social worker. C. Engage the client in non-threatening conversations. D. Encourage the client's family to visit more often.

Correct Answer is C

Explanation

A. Encouraging the client to participate in group activities may be beneficial but may not address the immediate need for increased communication and engagement.
B. Scheduling a daily conference with the social worker may provide support but may not directly address the client's withdrawal and noncommunicative behavior.
C. Engaging the client in non-threatening conversations is important to assess the client's current emotional state, understand the reasons for withdrawal, and provide support and encouragement for communication and interaction.
D. Encouraging the client's family to visit more often may be helpful for social support, but it may not address the underlying issue of the client's withdrawal and noncommunicative behavior.

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Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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Exhibits

The nurse reviews the post catheterization orders. Which two orders would the nurse question?