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Patient Data

Exhibits

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?

Place the child on a continuous cardiopulmonary monitor

Check pedal pulses every 4 hours

Point of care blood glucose

Admit to the pediatric floor for observation

Vital signs every 4 hours

Check dressing every 15 minutes for 1 hour and then every hour for 24 hours

NPO

Answer and Explanation

Correct Answer : C,G

Choice A reason: Placing the child on a continuous cardiopulmonary monitor is a standard post-operative order for monitoring the child’s heart and lung function after cardiac catheterization.
Choice B reason: Checking pedal pulses every 4 hours is important to ensure that there is adequate blood flow to the extremities, which can be compromised after cardiac procedures.
Choice C reason: Point of care blood glucose testing every 6 hours may not be necessary unless the child has a history of diabetes or there was a specific concern during the procedure. This order should be clarified with the physician.
Choice D reason: Admitting the child to the pediatric floor for observation is a standard procedure to monitor for any complications following cardiac catheterization.
Choice E reason: Monitoring vital signs every 4 hours is a typical post-operative order to ensure the child’s stability after the procedure.
Choice F reason: Checking the dressing every 15 minutes for 1 hour and then every hour for 24 hours is a standard order to monitor for bleeding or other complications at the catheterization site.
Choice G reason: The order for NPO status might need to be questioned depending on the time expected before the child can eat or drink again, especially considering the child’s age and the need for hydration and nutrition.
Choice H reason: Administering Lactated Ringers IV at 66 mL/hr while NPO is a standard order to maintain hydration while the child cannot take anything by mouth.

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Correct Answer is B

Explanation

Choice A reason: While nutrition is important, a high-protein diet is not specific to the management of heart failure.

Choice B reason: Weighing every morning allows for monitoring of fluid retention, which is a key aspect of managing heart failure.

Choice C reason: Range of motion exercises are good for overall health but are not specific to heart failure management.

Choice D reason: Limiting fluid intake is important, but it is more critical to monitor weight daily to detect fluid retention early.

A. Obtain a history of allergic reactions B. Document lying, sitting, and standing blood pressures C. Perform a mini mental exam on the child D. Determine when the child last ate E. Locate and mark the pedal pulses F. Measure the child’s height and weight

Correct Answer is ["A","B","D","E"]

Explanation

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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Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is B

Explanation

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.

Correct Answer is ["A","B","D","E"]

Explanation

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Patient Data

Exhibits

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?