A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?

"You should not have sexual intercourse while the monitor is in place."

"You can bathe while wearing the electrodes."

"You should remove the electrodes when you go to bed."

"You will need to record daily activities in a diary."

Answer and Explanation

The Correct Answer is D

A. "You should not have sexual intercourse while the monitor is in place.": This is incorrect because sexual activity is generally not restricted while wearing a Holter monitor. The main focus is on ensuring the monitor remains attached.
B. "You can bathe while wearing the electrodes.": This is incorrect because bathing or getting the electrodes wet can interfere with the monitor's functionality and potentially lead to inaccurate readings.
C. "You should remove the electrodes when you go to bed.": This is incorrect because the electrodes should remain in place for the full 24-hour period to ensure continuous monitoring.
D. "You will need to record daily activities in a diary.": This is correct as recording activities in a diary is crucial for correlating symptoms with the Holter monitor data.

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Correct Answer is A

Explanation

A. Increase the IV flow rate: This is correct as the client's blood pressure is low, which could indicate hypovolemia or shock. Increasing the IV flow rate can help improve blood volume and blood pressure.
B. Cover the client with a warm blanket: While this can help with hypothermia, it does not address the immediate concern of low blood pressure.
C. Compare the reading to the preoperative value: Comparing to the preoperative value can provide context but does not directly address the current low blood pressure.
D. Reassure the client: Reassuring the client is important but not the first priority. Addressing the physiological issue of low blood pressure should be the initial focus.

A. Presence of gag reflex B. Sore throat C. Facial edema D. Blood pressure 110/78 mm Hg

Correct Answer is C

Explanation

A. Presence of gag reflex: This is normal after a bronchoscopy as the gag reflex indicates that the client is recovering from sedation.
B. Sore throat: This is a common and expected finding after a bronchoscopy due to irritation of the throat.
C. Facial edema: This is correct as facial edema may indicate an allergic reaction or complication, and it should be reported to the provider immediately.
D. Blood pressure 110/78 mm Hg: This is within the normal range and does not typically require reporting unless there are other symptoms present.

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A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?

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