After teaching a client who has an implantable cardioverter- defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching?

"I will avoid sources of strong electromagnetic fields."

"Now I can discontinue my antidysrhythmic medication."

"I would participate in a strenuous exercise program."

"I would wear a snug-fitting shirt over the ICD."

Answer and Explanation

The Correct Answer is A

A. Clients with ICDs should avoid strong electromagnetic fields, which can interfere with the device’s function. This is crucial for safety.

B. Discontinuing antidysrhythmic medication is not recommended unless instructed by the healthcare provider, as it could increase the risk of arrhythmias.

C. Strenuous exercise may be too strenuous for someone with an ICD and could increase the risk of arrhythmias or lead to ICD activation.

D. A snug-fitting shirt is generally not recommended because it may place pressure on the ICD site and cause discomfort.

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Correct Answer is B

Explanation

A. Digoxin is used to control the heart rate in atrial fibrillation but does not directly prevent the common complication of thromboembolism.

B. Warfarin is an anticoagulant used to prevent thromboembolic complications, such as stroke, which are common in atrial fibrillation due to the formation of clots in the atria.

C. Furosemide is a diuretic used to manage fluid retention, often in heart failure, but it does not prevent thromboembolism.

D. Lisinopril is an ACE inhibitor used to manage hypertension and heart failure, but it does not prevent thromboembolic complications.

A. Administer multiple vitamins and minerals in the IV solution. B. Infuse total parenteral nutrition via a central catheter. C. Encourage an oral intake of at least 3000 kcal per day. D. Insert a feeding tube and initiate enteral feedings.

Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

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After teaching a client who has an implantable cardioverter- defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

Correct Answer is D

Explanation

A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?

What would be the priority intervention for the care of the client who is pulseless and has the following rhythm on the monitor?

When evaluating the effectiveness of preoperative teaching with a client scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the client says which of the following?

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?