Patient Data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A reason: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.
Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.
Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.
Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.
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