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 C

Explanation

A. Determine the last time the client had a bowel movement: While bowel movements may affect imaging studies of the abdomen, knowing the timing of the last bowel movement is not directly related to the safety or effectiveness of an IV pyelogram.
B. Inquire if the client has taken regularly scheduled medications: While it's important to know about medications, especially if they might interfere with the test or need to be temporarily
discontinued, the presence of an allergy to shellfish is more critical for IV pyelogram preparation.
C. Ask if the client has an allergy to shellfish: IV pyelogram contrast dye contains iodine, and some clients may be allergic to iodine-containing substances, including shellfish. An allergic reaction to the contrast dye could lead to serious complications.
D. Find out if the client can lie prone for the x-ray: While positioning is important for imaging studies, it's not as critical as ensuring the client does not have an allergy to the contrast dye.

A. "I can only give medical information to your child because the client is an adult." B. "I'm sorry, but your child's medical information is none of your business." C. "The healthcare provider will share this information with you." D. "I can give you those results as soon as I get them back from the lab."

Correct Answer is A

Explanation

Rationale for A: The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of medical information, and since the client is an adult, medical information can only be shared with the client or individuals the client designates. The nurse must follow these regulations and inform the parent appropriately.

Rationale for B: This response is inappropriate and disrespectful. While maintaining confidentiality is crucial, the language used should be sensitive and professional when discussing privacy issues with a parent.

Rationale for C: While the healthcare provider can discuss medical information, this response deflects responsibility. The nurse should clarify that medical information can only be shared with the client unless permission is granted.

Rationale for D: Offering to share lab results with the parent without the client's consent would violate HIPAA and the client's privacy rights, making this response incorrect.

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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.

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A client is scheduled for an IV pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

Correct Answer is C

Explanation

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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.