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

Explanation

A. Giving a bolus of 1,000 mL 0.9% sodium chloride is typically used to treat hypovolemia or electrolyte imbalances, which are not indicated by the patient's current lab values or clinical
situation.
B. Repeating the blood gas in 1 hour is a reasonable order as it would provide information on whether the patient's respiratory status is improving following interventions for ventilator-associated pneumonia.
C. Placing the client in a prone position can improve oxygenation in patients with respiratory distress by redistributing lung perfusion, making it a suitable intervention for this patient with diminished breath sounds and crackles.
D. Performing endotracheal suctioning would help clear secretions, which may be contributing to the patient's diminished breath sounds and crackles, and is consistent with the care for a patient with pneumonia.
E. A chest x-ray now would typically be ordered if there was a suspicion of a new onset condition such as a pneumothorax or pleural effusion, which is not indicated by the patient's current presentation.
F. Administering an inhaled corticosteroid is generally used for long-term management of chronic respiratory conditions and is not typically used for acute management of ventilator-associated pneumonia.

A. Shaking that changes the child's handwriting legibility. B. Bruises on both knees after the weekend. C. Sunburn with blisters on the face, arms, and hands. D. Refuses to complete written homework assignments. E. Thirst and frequent requests for bathroom breaks.

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

Explanation

A. Shaking that changes the child's handwriting legibility could indicate a neurological or motor issue and warrants further assessment by the school nurse.
B. Bruises on both knees after the weekend are likely minor and do not typically require immediate referral to the school nurse unless there are other concerning signs of abuse or injury.

C. Sunburn with blisters on the face, arms, and hands could indicate severe sunburn and potential complications such as infection or dehydration, requiring evaluation by the school nurse.
D. Refusing to complete written homework assignments may indicate behavioral issues or difficulties with learning but does not necessarily require immediate referral to the school nurse.

E. Thirst and frequent requests for bathroom breaks could indicate underlying medical issues such as diabetes or urinary tract infection and should be reported to the school nurse for further assessment.

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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

Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

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

Explanation

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

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

Explanation

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Exhibits

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