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 C
Explanation
Choice A reason: Encouraging the client to walk thirty minutes every day is a good practice but does not directly relate to the immediate outcome of managing chest pain.
Choice B reason: Monitoring blood glucose and blood pressure is part of ongoing management but is not a specific outcome related to exertional chest pain.
Choice C reason: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.
Choice D reason: A blood pressure reading of less than 160/90 mm Hg is less stringent than current guidelines suggest for optimal control in cardiovascular disease.
Correct Answer is B
Explanation
Choice A reason: While knowing if the client can lie prone is useful, it is not the most critical piece of information prior to an intravenous pyelogram.
Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.
Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.
Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.
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