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 D

Explanation

Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.

Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.

Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.

Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.

A. Mucous strings floating in the drainage. B. Red edematous stomal appearance. C. Stomal output of 40 mL in the last hour. D. Liquid brown drainage from the stoma.

Correct Answer is D

Explanation

Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.

Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.

Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.

Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.

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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

Correct Answer is D

Explanation

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

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.

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

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.