The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?

Correct Answer: A

Rationale: After a cardiac catheterization, the nurse should be assessing for the development of cardiac arrhythmias, as this is a potential complication associated with the procedure. Cardiac arrhythmias can occur due to irritation of the heart during the catheterization, changes in electrolyte levels, or other factors related to the procedure. Monitoring the child's cardiac rhythm closely allows for early detection and management of arrhythmias to prevent serious complications. While other complications such as hypostatic pneumonia, heart failure, and rapidly increasing blood pressure can also occur, cardiac arrhythmia is the most important complication to assess for immediately post-cardiac catheterization.

Correct Answer: C

Rationale: In septic shock, vasoconstriction is a common phenomenon. This occurs as part of the body's response to the infection, where blood vessels constrict in an attempt to maintain blood pressure and perfusion to vital organs. The vasoconstriction leads to increased systemic vascular resistance and contributes to the hypotension seen in septic shock. The body's natural response to infection also involves a release of inflammatory mediators, which can cause vasodilation in some areas while concurrent vasoconstriction occurs in others, resulting in uneven blood flow distribution and contributing to organ dysfunction. Therefore, vasoconstriction is a key factor in the pathophysiology of septic shock.

Correct Answer: B

Rationale: Nocturia is the condition of waking up during the night to urinate. The factors associated with it are usually related to Increased nocturnal urine production (2), aging and hormonal changes (3), underlying medical conditions such as diabetes and heart disease (5), and medications that can increase urine production or cause fluid retention (6). Therefore, the correct choices are 2, 3, 5, and 6 which align with B.

Correct Answer: A

Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.

Correct Answer: C

Rationale: Insensible losses are the fluid losses that occur without the individual being aware of it, such as through breathing, sweating, and through the skin. In an afebrile person, insensible losses are normally around 600ml per 24 hours. This amount can vary depending on factors such as temperature, humidity, and individual metabolism. When a patient is febrile and experiencing diaphoresis (excessive sweating), the fluid output can increase significantly due to the body's attempts to cool itself down. It is important for the nurse to consider these increased fluid losses when planning fluid replacement for a febrile patient to prevent dehydration.