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:While a voiding diary can be useful for monitoring urinary symptoms, the client’s description of urinary retention symptoms requires immediate assessment for bladder distention or obstruction, not just recording voiding patterns.
B: Obtaining a urine specimen is important if a urinary tract infection is suspected, but the symptoms described are more indicative of urinary retention, possibly due to prostate issues, which requires immediate physical assessment.
C:The client’s symptoms suggest urinary retention, which can be detected by palpating the suprapubic area for bladder distention. This is the most immediate assessment to determine if the client has retained urine in the bladder.
D: Cleansing the glans penis is important for hygiene and may prevent infections, but it does not address the underlying issue of bladder fullness and urinary retention.
Correct Answer is D
Explanation
A. Holding hands below elbows when rinsing is a correct technique to prevent contamination of washed hands.
B. Lathering using a circular movement is a correct technique for thorough handwashing.
C. Washing for a total of 20 seconds is in line with the recommended duration for effective handwashing.
D. Turning the water off using bare hands can potentially recontaminate the hands. Instead, a paper towel or elbow should be used to turn off the faucet after washing hands to prevent recontamination. Therefore, this action by the UAP requires additional teaching.
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