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Patient Data

Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Prepare for a cesarean delivery

Administer calcium gluconate

Obtain blood pressure

Stop infusion of magnesium

Increase IV fluids

Administer oxygen

Obtain serum magnesium level

Make preparations to prevent cardiac arrest

Answer and Explanation

Correct Answer : B,C,F,G,H

Choice A reason: Preparing for a cesarean delivery is not indicated solely based on the information provided. The patient is at 36 weeks with moderate pre-eclampsia and there are no immediate signs of fetal distress or a need for emergency delivery based on the nurse’s notes.
Choice B reason: Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient’s decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention.
Choice C reason: Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues.
Choice D reason: Stopping the infusion of magnesium sulfate is not indicated at this time. While the patient’s decreased LOC and absent DTRs are concerning, magnesium sulfate is critical for preventing seizures in pre-eclampsia and should not be stopped without clear signs of overdose and physician consultation.
Choice E reason: Increasing IV fluids is not indicated and could be harmful. The patient already has pulmonary edema and increasing fluids could exacerbate this condition, especially in the context of pre-eclampsia where fluid management needs to be carefully balanced.
Choice F reason: Administering oxygen is correct as the patient’s oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician’s orders.
Choice G reason: Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient’s symptoms of decreased LOC and absent DTRs.
Choice H reason: Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

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Correct Answer is A

Explanation

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

A. Monitor for fever B. Give only clear liquids for several days C. Avoid any kind of bath or shower D. Keep a pressure dressing on the site for one week E. Alert the physician if the site bleeds or swells F. The child may take ibuprofen for pain

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

Explanation

Choice A reason: Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening.
Choice B reason: There is no need to restrict the child to clear liquids for several days unless specifically instructed by the physician for a particular reason. After cardiac catheterization, patients are usually encouraged to resume their normal diet as tolerated to promote recovery unless there are other concerns that warrant dietary restrictions1.
Choice C reason: Avoiding baths or showers is generally recommended immediately after cardiac catheterization to prevent infection at the catheter insertion site. However, this restriction is usually only for a few days, not indefinitely. The site needs to be kept dry and clean until it has sufficiently healed.
Choice D reason: Keeping a pressure dressing on the site for one week is not typically necessary. The dressing is usually checked and changed by healthcare professionals, and the site is monitored for healing. The dressing may be removed after a certain period, often before one week, as long as there are no signs of bleeding or infection.
Choice E reason: Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection.
Choice F reason: The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it’s important to use the correct dosage and to ensure it doesn’t interfere with any other medications the child may be taking.

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Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

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Naxlex Comprehensive Predictor Exams

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Correct Answer is A

Explanation

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

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

Explanation

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Patient Data

Exhibits

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.