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
- Choice A Rationale: Assuming care of the client and assigning the PN to another client would disrupt the workflow and could lead to confusion. It is important for continuity of care that the PN who began the procedure with the client carries it through to completion.
- Choice B Rationale: Arranging for unlicensed assistive personnel to assist may not be appropriate as they may not have the training or skills required to assist with a sigmoidoscopy, which could compromise patient safety and the integrity of the procedure.
- Choice C Rationale: Acknowledging that the PN has positioned the client safely and correctly would be incorrect because a flat prone position is not the recommended position for a sigmoidoscopy, which typically requires the client to be in a left lateral or Sims' position.
- Choice D Rationale: Demonstrating to the PN how to position the client more effectively is the correct action because it ensures that the client is in the proper position for a sigmoidoscopy, which can enhance the effectiveness of the procedure and patient comfort.
Correct Answer is D
Explanation
- A: This choice is incorrect because a flat prone position is not safe or correct for a sigmoidoscopy; the client should be in a left lateral or Sims' position.
- B: This choice is not directly related to the immediate need of correcting the client's position for the procedure.
- C: Assuming care of the client does not address the immediate issue of the client's incorrect positioning for the sigmoidoscopy.
- D: Demonstrating the correct positioning ensures the safety and effectiveness of the procedure, which is the nurse's responsibility.
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