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Patient Data

Exhibits

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?

Place the child on a continuous cardiopulmonary monitor

Check pedal pulses every 4 hours

Point of care blood glucose

Admit to the pediatric floor for observation

Vital signs every 4 hours

Check dressing every 15 minutes for 1 hour and then every hour for 24 hours

NPO

Answer and Explanation

Correct Answer : C,G

Choice A reason: Placing the child on a continuous cardiopulmonary monitor is a standard post-operative order for monitoring the child’s heart and lung function after cardiac catheterization.
Choice B reason: Checking pedal pulses every 4 hours is important to ensure that there is adequate blood flow to the extremities, which can be compromised after cardiac procedures.
Choice C reason: Point of care blood glucose testing every 6 hours may not be necessary unless the child has a history of diabetes or there was a specific concern during the procedure. This order should be clarified with the physician.
Choice D reason: Admitting the child to the pediatric floor for observation is a standard procedure to monitor for any complications following cardiac catheterization.
Choice E reason: Monitoring vital signs every 4 hours is a typical post-operative order to ensure the child’s stability after the procedure.
Choice F reason: Checking the dressing every 15 minutes for 1 hour and then every hour for 24 hours is a standard order to monitor for bleeding or other complications at the catheterization site.
Choice G reason: The order for NPO status might need to be questioned depending on the time expected before the child can eat or drink again, especially considering the child’s age and the need for hydration and nutrition.
Choice H reason: Administering Lactated Ringers IV at 66 mL/hr while NPO is a standard order to maintain hydration while the child cannot take anything by mouth.

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Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings may not be the best initial approach for inverted nipples as it could lead to nipple confusion and interfere with breastfeeding.

Choice B reason: While teaching about the use of a breast pump is helpful for expressing milk, it does not directly address the issue of latching with inverted nipples.

Choice C reason: A breast shield can be beneficial for mothers with inverted nipples as it can help draw out the nipple, allowing the baby to latch on more effectively.

Choice D reason: Using ice on the areola is not a recommended practice for addressing inverted nipples as it can cause discomfort and is not a reliable method for improving latch.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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

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Patient Data

Exhibits

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?