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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.

Nursing Test Bank

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

Explanation

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment findings

Neurological Alert and oriented times 4.
Cardiovascular WNL.
Respiratory WNL.
Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.
Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.
Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

A. Chewable children's aspirin will help prevent inflammation. B. Any level of fever is serious and should be reported right away. C. Keep the child home from daycare for the next two days. D. Apply a cool pack to the injection site to reduce discomfort.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A parent asks the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Correct Answer is D

Explanation

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Patient Data Exhibits The nurse reviews the client data. What increases the client's chance for positive outcomes after the completion of the bariatric surgery? Select all that apply.

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Patient Data

Exhibits

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?