Patient Data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While living in older housing projects can pose a risk, the age of the child and their behaviors, such as hand-to-mouth activities, make younger children more susceptible.
Choice B reason: A 2-year-old is at the highest risk due to their developmental stage, which includes frequent hand-to-mouth activity and the likelihood of playing in soil or dust that may be contaminated with lead.
Choice C reason: Adolescents working in a paint factory may be exposed to lead; however, they are less likely to engage in hand-to-mouth behaviors that lead to ingestion, which is the primary route of lead poisoning in children.
Choice D reason: A 10-year-old with Type 1 diabetes mellitus does not have an increased risk of lead poisoning based on their condition alone.
Correct Answer is C
Explanation
Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.
Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.
Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.
Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.
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