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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings may not be the best initial approach for inverted nipples as it could lead to nipple confusion and interfere with breastfeeding.

Choice B reason: While teaching about the use of a breast pump is helpful for expressing milk, it does not directly address the issue of latching with inverted nipples.

Choice C reason: A breast shield can be beneficial for mothers with inverted nipples as it can help draw out the nipple, allowing the baby to latch on more effectively.

Choice D reason: Using ice on the areola is not a recommended practice for addressing inverted nipples as it can cause discomfort and is not a reliable method for improving latch.

A. Use standard precautions and wear a mask. B. Explain the purpose of a low bacteria diet. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Monitor the client's white blood cell count.

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

Explanation

Choice A reason: Standard precautions are always used, but a mask is not specifically required unless performing a procedure that risks splashing. MRSA is primarily spread through direct contact, so masks are not the main precaution for this client.

Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.

Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.

Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.

Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.

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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

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

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Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

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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.