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 ["B","C","D","E"]

Explanation

A. Explaining the purpose of a low bacteria diet is not directly relevant to the management of osteomyelitis or MRSA infection. This intervention would not be included in the plan of care.
B. Using standard precautions and wearing a mask is essential when caring for a client with an open draining wound, especially when MRSA infection is suspected. This helps prevent the spread of infection to healthcare workers and other clients.
C. Sending wound drainage for culture and sensitivity is important to identify the causative organism and determine the most effective antibiotic therapy.
D. Monitoring the client's white blood cell count is important for assessing the client's response to treatment and detecting any signs of worsening infection.
E. Instituting contact precautions for staff and visitors is necessary to prevent the transmission of MRSA to others. This includes wearing gowns and gloves when entering the client's room and ensuring proper hand hygiene practices are followed.

A. Monitor skin elasticity. B. Assess body temperature. C. Measure urinary output. D. Observe aspiration site.

Correct Answer is D

Explanation

A. Monitoring skin elasticity is important for assessing hydration status but is not directly related to the risk of bleeding after a bone marrow biopsy in a client with thrombocytopenia.
B. Assessing body temperature is important for detecting signs of infection but is not the most immediate concern following a bone marrow biopsy in a client with thrombocytopenia.
C. Measuring urinary output is important for assessing renal function but is not the most immediate concern following a bone marrow biopsy in a client with thrombocytopenia.
D. Observing the aspiration site is the most important assessment following a bone marrow biopsy in a client with thrombocytopenia because thrombocytopenia increases the risk of
bleeding at the site. It is crucial to monitor for signs of bleeding, such as hematoma formation or continued bleeding, and to apply pressure as needed to prevent or control bleeding.

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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

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Correct Answer is D

Explanation

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The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

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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.