Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization.

What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Measure the child's height and weight

Document lying, sitting, and standing blood pressures

Locate and mark the pedal pulses

Perform a mini mental exam on the child

Obtain a history of allergic reactions

Determine when the child last ate

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Measuring the child's height and weight is essential to ensure appropriate dosing of medications and to assess the child's growth and development.
B. Documenting lying, sitting, and standing blood pressures can help detect orthostatic hypotension, which may be a concern during or after the procedure.
C. Locating and marking the pedal pulses is important for assessing the vascular status of the lower extremities, especially since the catheterization involves accessing a blood vessel.
D. Performing a mini mental exam on the child is not typically part of the pre-cardiac catheterization assessment for a 3-year-old.
E. Obtaining a history of allergic reactions is crucial to prevent any potential allergic response to medications or materials used during the catheterization.
F. Determining when the child last ate is necessary because the child will need to fast for a certain period before the procedure to reduce the risk of aspiration.

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Correct Answer is A

Explanation

A. Weigh every morning: Daily weighing helps monitor for fluid retention, which is important in managing heart failure. Sudden weight gain can indicate fluid accumulation and worsening heart failure symptoms, prompting the need for medical attention.
B. Limit fluid intake to 1,500 ml daily: While fluid restriction may be necessary for some
individuals with heart failure, the specific amount varies based on individual circumstances and should be determined by the healthcare provider. A blanket recommendation of 1,500 ml may not be appropriate for all patients.
C. Eat a high protein diet: While a balanced diet is important for overall health, there is no specific evidence to suggest that a high protein diet is essential for heart failure management. Dietary recommendations should be tailored to the individual's needs and comorbidities.
D. Perform range of motion exercises: While exercise is important for overall health, including for individuals with heart failure, range of motion exercises may not be the priority instruction for discharge teaching. Exercise recommendations should be individualized and may include aerobic and resistance training based on the client's condition and functional status.

A. The client will monitor blood glucose and blood pressure after each meal. B. The client's blood pressure readings will be less than 160/90 mm Hg. C. The nurse will encourage the client to walk thirty minutes every day. D. The client's daily blood pressure will be less than 140/80 mm Hg this month.

Correct Answer is D

Explanation

A. The client will monitor blood glucose and blood pressure after each meal: While monitoring blood pressure may be important for cardiovascular health, this outcome specifically addresses blood glucose, which may not be directly related to the client's newly diagnosed cardiovascular disease.
B. The client's blood pressure readings will be less than 160/90 mm Hg: This outcome focuses on blood pressure control, but the goal of less than 160/90 mm Hg may not be stringent enough for optimal cardiovascular health.
C. The nurse will encourage the client to walk thirty minutes every day: Exercise is important for cardiovascular health, but this outcome does not specifically address blood pressure
management, which is crucial for reducing the risk of cardiovascular events.
D. The client's daily blood pressure will be less than 140/80 mm Hg this month: This outcome addresses blood pressure control, setting a specific target (less than 140/80 mm Hg) that aligns with current guidelines for managing cardiovascular disease and reducing the risk of
complications.

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Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Nursing Test Bank

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Explanation

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Exhibits

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization.

What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.