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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.

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Correct Answer is A

Explanation

A. Initiating neurological monitoring every 2 hours is critical for a client with a TIA. This allows for early detection of any changes in neurological status, which could indicate worsening conditions or the onset of a stroke. Monitoring helps ensure prompt intervention if symptoms escalate.

B. While assessing bilateral breath sounds is important for overall respiratory function, it is not the most urgent priority in managing a TIA. Neurological assessments take precedence in this situation.

C. Reviewing the client's daily medications is important for understanding potential risk factors and management, but it is a secondary intervention. Neurological monitoring takes priority in the acute phase of care for a TIA.

D. Palpating the suprapubic region for urinary retention is more relevant in clients at risk for retention due to neurological or urological issues but is not a primary concern in managing a TIA. The focus should be on neurological function.

A. Have the client breathe into a paper bag. B. Ask the client to take short, rapid breaths. C. Instruct the client in pursed lip breathing. D. Increase oxygen to three L/minute.

Correct Answer is C

Explanation

A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.

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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

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula is currently short of breath. Which action should the nurse take?

Correct Answer is C

Explanation

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Exhibits

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