A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Physical therapy

Low-sodium diet

MRI of the chest

Serum cardiac enzyme levels

Answer and Explanation

The Correct Answer is C

A. Physical therapy is generally appropriate and beneficial post-surgery for mobility and rehabilitation.
B. A low-sodium diet is often recommended for heart health but is not specific to pacemaker insertion.
C. MRI of the chest should be clarified because the magnetic fields from MRI machines can interfere with the pacemaker’s function.
D. Serum cardiac enzyme levels are relevant for monitoring heart function and are appropriate.

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Correct Answer is B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

A. Decrease in the urinary output from 50 mL to 30 mL per hour. B. Increase in the heart rate from 88 to 110/min. C. Decrease in the respiratory rate from 20 to 16/min. D. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).

Correct Answer is B

Explanation

A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.

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A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Nursing Test Bank

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