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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Frequent premature ventricular contractions: While abnormal heart rhythms are a concern, they may not warrant immediate intervention in this context unless they are causing significant hemodynamic instability.
B. Paroxysmal supraventricular tachycardia: This cardiac dysrhythmia may require intervention but is not directly related to the administration of alteplase.
C. Lower extremity edema: Lower extremity edema may indicate venous insufficiency or other underlying conditions but is not directly related to the administration of alteplase.
D. Headache with blurred vision: This could be indicative of worsening cerebral edema or increased intracranial pressure, which are potential complications of alteplase administration and require immediate intervention.
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.
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