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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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Initiating neurological monitoring every 2 hours is critical for a client with a TIA. This allows for early detection of any changes in neurological status, which could indicate worsening conditions or the onset of a stroke. Monitoring helps ensure prompt intervention if symptoms escalate.

B. While assessing bilateral breath sounds is important for overall respiratory function, it is not the most urgent priority in managing a TIA. Neurological assessments take precedence in this situation.

C. Reviewing the client's daily medications is important for understanding potential risk factors and management, but it is a secondary intervention. Neurological monitoring takes priority in the acute phase of care for a TIA.

D. Palpating the suprapubic region for urinary retention is more relevant in clients at risk for retention due to neurological or urological issues but is not a primary concern in managing a TIA. The focus should be on neurological function.

A. Maintain sequential compression devices while in bed. B. Teach client to use incentive spirometer every 2 hours while awake. C. Assess pain level and medicate PRN as prescribed. D. Remove urinary catheter as soon as possible and encourage voiding. E. Administer low molecular weight heparin as prescribed.

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

Explanation

SCDs are effective for preventing DVT but are not directly related to infection prevention. The focus here is more on preventing respiratory and urinary infections.

B. Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent
atelectasis and pneumonia by promoting deep breathing and lung expansion, reducing the risk of respiratory infections.
C. Assessing pain level and medicating PRN as prescribed is important for postoperative comfort but is not directly related to reducing the risk of infection.
D. Removing the urinary catheter as soon as possible and encouraging voiding helps reduce the risk of urinary tract infections, which are common in clients with prolonged catheter use.
E. Low molecular weight heparin helps prevent blood clots, reducing the risk of thrombosis, which can increase the risk of postoperative complications, including infections.

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Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

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Naxlex Comprehensive Predictor Exams

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

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Exhibits

The nurse reviews the post catheterization orders. Which two orders would the nurse question?