Answer to Question 1
ANS: A
Polycythemia (hemoglobin >15 g/dL) predisposes a child to thrombotic events, including stroke. The nurse would ask about an anticoagulant. A fluid restriction would thicken the blood even further, increasing the risk of thrombotic events. The nurse should be able to obtain an oxygen saturation as an independent nursing assessment. There is not enough information about the patient to recommend cardiac rehabilitation.
Answer to Question 2
ANS: B
All actions are important for the child undergoing open heart surgery. However, the priority for any surgical patient is to ensure complete informed consent is on the chart.
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