Exhibits
The nurse reviews the post catheterization orders. Which two orders would the nurse question?
Give lactated Ringers IV at 66 mL/hr while NPO
Vital signs every 4 hours
Place the child on a continuous cardiopulmonary monitor
Admit to the pediatric floor for observation
NPO
Point of care blood glucose
Check pedal pulses every 4 hours
Correct Answer : A,F
A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clients who incurred disease complications promptly received rehabilitation: This outcome suggests that the focus is on secondary prevention rather than primary prevention.
B. More than half of at-risk clients were diagnosed early in their disease process: While early diagnosis is important, it is not a direct measure of the effectiveness of a primary prevention program.
C. Average client scores improved on specific risk factor knowledge tests: This outcome indicates that clients are better informed about risk factors for sexually transmitted diseases, suggesting that the primary prevention program has been effective in increasing awareness and knowledge.
D. New screening protocols were developed, validated, and implemented: While developing new screening protocols may be beneficial, it does not directly measure the effectiveness of the
primary prevention program.
Correct Answer is B
Explanation
A. Mild sedation is a common side effect of ramelteon and typically does not require immediate medical attention. It may improve with continued use as the body adjusts to the medication.
B. Somnambulism (sleepwalking) is a less common but potentially serious side effect of ramelteon. It can pose safety risks to the client, and the healthcare provider should be notified promptly to assess the severity and determine if the medication needs to be adjusted or
discontinued.
C. A change in the sleep-wake cycle is a common intended effect of ramelteon as it helps regulate sleep patterns. However, if the change is extreme or disruptive, it may warrant further evaluation by the healthcare provider.
D. Dizziness reported after the initial dose is a common side effect of ramelteon and usually
diminishes with continued use. It may not require immediate medical attention unless it persists or worsens.
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