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 B

Explanation

Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.

Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.

Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.

Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.

Correct Answer is ["67"]

Explanation

Step 1: Convert the volume of fluid to be infused from mL to mL (since the rate is usually measured in mL/hr):

100 mL = 100 mL (No conversion needed as the volume is already in mL)

Step 2: Convert the time for infusion from hours to hours (since the rate is usually measured in mL/hr):

1.5 hours = 1.5 hours (No conversion needed as the time is already in hours)

Step 3: Calculate the rate (volume ÷ time):

Rate = Volume ÷ Time

Rate = 100 mL ÷ 1.5 hours

Rate = 66.67 mL/hr

So, the nurse should program the infusion pump to deliver at a rate of 67 mL/hr (rounded to the nearest whole number

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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

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?

Correct Answer is B

Explanation

Correct Answer is ["67"]

Explanation

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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.