A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Oxygen saturation increased from 88% to 96%. Beta blockers are medications that work by blocking the effects of adrenaline on the beta receptors in the body, specifically in the heart. By blocking these receptors, beta blockers reduce the heart rate and cardiac output, leading to a decrease in oxygen demand by the heart muscle. This decrease in oxygen demand can result in an increase in oxygen saturation levels as the heart works more efficiently. Option A is incorrect because beta blockers typically lower blood pressure by reducing the force of contraction of the heart and dilating blood vessels, not increasing it. Option B is incorrect as beta blockers can cause a slight decrease in respiratory rate due to their effect on the central nervous system, but a decrease from 25 to 14 breaths/min is too drastic and would be concerning. Option C is incorrect as beta blockers are known to decrease the heart rate, so a drop from 100 to 80 beats/min is expected and not a cause for concern. Educationally, understanding the pharmacological effects of beta blockers is crucial for nurses caring for patients receiving these medications, especially in cardiovascular conditions. Monitoring vital signs and oxygen saturation post-administration is essential to assess the medication's effectiveness and potential side effects. This rationale highlights the importance of knowing the expected outcomes of medication administration and recognizing normal and abnormal assessment findings in patients receiving beta blockers.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to compare the current pulmonary artery pressure reading with previous readings (Option A). This is crucial as it provides a baseline for comparison and helps in understanding the trend of the client's condition post-myocardial infarction. This action is essential for effective monitoring and management of cardiovascular conditions in pediatrics. Option B, increasing the intravenous fluid rate because the readings are low, is incorrect as solely relying on numerical values without proper assessment can lead to potential harm. Pulmonary artery pressure readings are not solely indicative of fluid status, and other factors need to be considered. Option C, immediately notifying the healthcare provider of the elevated pressures, is incorrect because the pressure readings are not significantly elevated to warrant urgent notification. It is important to assess the situation thoroughly before escalating to the healthcare provider. Option D, documenting the finding as the only action, is incorrect because action should be taken based on the assessment findings before documentation. In healthcare, timely and appropriate interventions are crucial in providing safe and effective care. Educationally, understanding how to interpret and prioritize assessments in cardiovascular conditions is vital for nursing practice. By comparing current readings with previous ones, nurses can make informed decisions and collaborate effectively with the healthcare team to optimize patient outcomes.

Correct Answer: C

Rationale: The correct answer to the question is option C: "Tell me more about your concerns about the surgery." This response is the most therapeutic and supportive approach in this situation. By encouraging the client to express their fears and concerns, the nurse can establish trust, provide emotional support, and address any specific worries the client may have. This approach allows for open communication and helps the nurse to better understand the client's emotional state, enabling them to provide appropriate care and support. Option A is incorrect because minimizing the client's fears by stating that the surgery is routine and has a low risk of death may come across as dismissive and invalidating of the client's emotions. It does not address the client's specific concerns or provide emotional support. Option B, suggesting speaking with a chaplain, may be appropriate for some clients, but in this case, the client is expressing fear of death related to the surgery itself. Referring to a chaplain may not directly address the client's concerns about the surgery and may not be the most immediate or appropriate response. Option D, asking about the client's support systems, is also not the best response in this situation as it does not directly address the client's expressed fear of death. While support systems are important, the immediate priority is addressing the client's emotional needs and concerns about the upcoming surgery. In an educational context, it is crucial for nurses to develop strong communication skills to effectively address and support clients' emotional needs. Encouraging open dialogue, active listening, and providing emotional support are essential components of holistic nursing care, especially in situations where clients are facing significant medical procedures or uncertainties. By acknowledging and validating the client's emotions, nurses can build trusting relationships and provide individualized, compassionate care.

Correct Answer: D

Rationale: Preoperative teaching should always be directed at the child’s stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.

Correct Answer: C

Rationale: Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.