A nurse is caring for a client who was recently admitted and has symptomatic bradycardia.

Exhibits

The nurse is caring for the client immediately following the insertion of the permanent pacemaker.

Complete the following sentence by using the list of options.

The nurse should monitor the client for
dropdown
and
dropdown
following permanent pacemaker placement.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Incisional Site Bleeding: This is important to check as it indicates possible complications like infection or hematoma formation at the pacemaker insertion site.
Bradycardia: It is essential to ensure that the pacemaker is functioning correctly and managing bradycardia as intended. Continuous monitoring is needed to detect any issues related to pacemaker settings or lead placements.

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Correct Answer is ["A","E"]

Explanation

A. Place a pillow under the client's head.
Rationale: This action helps to prevent head injury during a seizure by cushioning the head.
B. Place the client into a supine position.
Rationale: This is incorrect because it can increase the risk of aspiration. The client should be placed in a side-lying position to allow the mouth to drain and prevent aspiration.
C. Apply restraints.
Rationale: This is incorrect as restraints can cause injury to the client during a seizure. The nurse should instead ensure the environment is safe and free from objects that could harm the client.
D. Insert a bite stick into the client's mouth.
Rationale: This is incorrect because inserting any object into the mouth during a seizure can cause dental injury or aspiration. The jaw should not be forced open.
E. Loosen restrictive clothing.
Rationale: This action helps to prevent injury and allows for easier breathing during a seizure. It also prevents any constriction that could occur due to muscle contractions.

A. Place the client in a supine position. B. Use log rolling to reposition the client. C. Place a warming blanket on the client. D. Instruct the client to cough and deep breathe.

Correct Answer is B

Explanation

A. Placing the client in a supine position can increase ICP. The head of the bed should be elevated 30-45 degrees to promote venous drainage from the head.
B. Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
C. A warming blanket is not typically necessary unless the client is hypothermic; it does not directly affect ICP management.
D. Instructing the client to cough and deep breathe can increase ICP and should be avoided in clients with elevated ICP.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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