Patient Data

Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

Obtain a history of allergic reactions

Document lying, sitting, and standing blood pressures

Perform a mini mental exam on the child

Determine when the child last ate

Locate and mark the pedal pulses

Measure the child’s height and weight

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Obtaining a history of allergic reactions is crucial because the child will be exposed to various substances during cardiac catheterization, such as contrast dye, which could potentially cause an allergic reaction.
Choice B reason: Documenting lying, sitting, and standing blood pressures is important to assess for orthostatic hypotension, which could indicate volume depletion or cardiovascular problems that need to be addressed before the procedure.
Choice C reason: Performing a mini mental exam on the child is not typically part of the pre-procedure assessment for cardiac catheterization, especially given the young age of the child.
Choice D reason: Determining when the child last ate is essential because the child needs to have an empty stomach to reduce the risk of aspiration during sedation.
Choice E reason: Locating and marking the pedal pulses is important to establish baseline data so that post-procedure, any changes in the strength or presence of these pulses can be quickly identified, indicating potential complications.
Choice F reason: Measuring the child’s height and weight is generally part of a routine assessment but is not specifically focused on the pre-cardiac catheterization assessment unless dosing of medication or anesthesia is required based on weight.

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Correct Answer is ["A","C","D"]

Explanation

The correct answer is: a, c, d.

Choice A: Avoid prolonged standing or sitting

Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.

Choice B: Cross legs at the knee but not at the ankle

Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.

Choice C: Continue wearing compression stockings

Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.

Choice D: Use a recliner for long periods of sitting

Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.

Choice E: Maintain the bed flat while sleeping

Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.

A. Evaluate the effectiveness of this measure to stimulate client voiding. B. Recommend a complete bath to cleanse the perineal area more fully. C. Suggest contacting the healthcare provider for a prescription for catheter insertion. D. Instruct the PN that this technique promotes infection in elderly females.

Correct Answer is A

Explanation

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

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Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Avoid prolonged standing or sitting

Choice B: Cross legs at the knee but not at the ankle

Choice C: Continue wearing compression stockings

Choice D: Use a recliner for long periods of sitting

Choice E: Maintain the bed flat while sleeping

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Correct Answer is A

Explanation

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?

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A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

A client who weighs 110 lbs has received a prescription for dalteparin, 150 units/kg to be administered subcutaneously daily for 4 months. The medication is available in a 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Please enter the numerical value only.)

A client is scheduled for an intravenous pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

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

Patient Data

Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.