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","D","E"]

Explanation

A. Loss of sensation to the left lower extremity warrants immediate intervention as it may indicate nerve damage, impaired circulation, or compartment syndrome. These findings require urgent evaluation to prevent permanent damage.

B. Sloughing tissue around wound edges is a common finding in burn injuries during the healing process. While it requires monitoring and proper wound care, it does not necessitate immediate intervention unless accompanied by signs of infection.

C. Weeping serosanguineous fluid from wounds is expected in burn injuries, especially in the early stages of healing. This finding does not indicate an acute complication.

D. Reporting increased pain and pressure is a critical finding as it may indicate compartment syndrome, a condition where increased pressure within a muscle compartment impairs circulation and tissue viability. Immediate intervention is required to prevent further complications.

E. A change in the quality of peripheral pulses is an alarming finding as it suggests impaired circulation, potentially due to edema, vascular compromise, or compartment syndrome. This requires prompt assessment and action to restore adequate blood flow.

A. Monitor and document strict intake and output. B. Assess the serum potassium level every 4 hours. C. Obtain a 12-lead electrocardiogram daily. D. Evaluate glucose levels before and after meals.

Correct Answer is C

Explanation

A. Monitor and document strict intake and output: While monitoring intake and output is
important in managing fluid balance, it may not directly address the potential complications associated with hyperkalemia and hyperglycemia.
B. Assess the serum potassium level every 4 hours: While monitoring potassium levels is important, obtaining a 12-lead electrocardiogram provides immediate information about the cardiac effects of hyperkalemia, which can be life-threatening.
C. Obtain a 12-lead electrocardiogram daily: Hyperkalemia can lead to serious cardiac arrhythmias, including bradycardia, heart block, and ventricular fibrillation. Daily
electrocardiograms can help detect these changes early.
D. Evaluate glucose levels before and after meals: While monitoring glucose levels is important, the immediate concern in this scenario is the potential cardiac effects of hyperkalemia.

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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

Naxlex Comprehensive Predictor Exams

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.

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

Explanation

Correct Answer is C

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.