Patient Data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F","H"]
Explanation
Choice A reason: Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT.
Choice B reason: Maintaining strict bedrest for 12 hours after surgery is not typically recommended as it can increase the risk of complications such as DVT and pulmonary embolism. Early mobilization is generally encouraged to promote circulation and respiratory function.
Choice C reason: Providing chilled beverages is not a specific nursing intervention indicated in the immediate postoperative period for bariatric surgery patients. Fluid intake should be carefully monitored and regulated, but the temperature of the beverages is not a primary concern.
Choice D reason: Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues.
Choice E reason: Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively.
Choice F reason: Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention.
Choice G reason: Keeping the client NPO (nothing by mouth) is a common immediate postoperative order, but as the patient progresses, they will be started on a liquid diet and advanced as tolerated. Therefore, it is not a nursing intervention that would be indicated indefinitely.
Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.
Correct Answer is B
Explanation
Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.
Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.
Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.
Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.
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