The nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?

Give the scheduled dose of diltiazem (Cardizem).

Reposition the patient on the left side.

Have the patient perform the Valsalva maneuver.

Apply the transcutaneous pacemaker (TCP) pads

Answer and Explanation

The Correct Answer is D

Sinus bradycardia with a heart rate of 32 beats/min and accompanying hypotension and symptoms of feeling faint indicates significant hemodynamic compromise. In such cases, the first-line intervention is to provide external cardiac pacing through transcutaneous pacemaker (TCP) pads. TCP can help increase the heart rate and improve cardiac output by delivering electrical impulses to the heart.

Administering the scheduled dose of diltiazem (Cardizem), a calcium channel blocker, is not appropriate in this situation. Diltiazem can further lower the heart rate and blood pressure, exacerbating the client's symptoms and potentially leading to adverse effects.

Repositioning the patient on the left side or having the patient perform the Valsalva maneuver are not effective interventions for treating sinus bradycardia with hemodynamic compromise. These actions may be used in specific situations, but in this case, the client requires immediate intervention to address the low heart rate and blood pressure.

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Correct Answer is B

Explanation

The most appropriate intervention for a client diagnosed with peripheral arterial insufficiency is: Encourage the client to engage in a moderate amount of exercise. Peripheral arterial insufficiency is a condition characterized by reduced blood flow to the extremities, typically the legs, due to narrowed or blocked arteries. Regular exercise is an important component of managing peripheral arterial insufficiency. Exercise helps improve circulation, promote collateral blood vessel development, and increase the distance a client can walk before experiencing pain (intermittent claudication). Therefore, encouraging the client to engage in a moderate amount of exercise, such as walking, under healthcare provider guidance is crucial.]

The other options are not appropriate interventions for peripheral arterial insufficiency:

Elevating the legs and arms above the heart when resting: While elevation can be beneficial for certain conditions, such as reducing swelling in venous insufficiency, it is not the primary intervention for peripheral arterial insufficiency. Elevation alone does not improve arterial blood flow and may not effectively address the underlying circulatory issues.

Encouraging extended periods of sitting or standing: Prolonged sitting or standing can further restrict blood flow and exacerbate symptoms in clients with peripheral arterial insufficiency. Encouraging regular movement and avoiding prolonged immobility is important to maintain adequate circulation.

Discouraging walking in order to limit pain: While walking may cause pain or discomfort in clients with peripheral arterial insufficiency (intermittent claudication), it is important to encourage walking as part of an exercise regimen. Walking helps improve symptoms over time and promotes overall cardiovascular health.

A. Notify HCP of any redness or irritation of incision. B. Do not lift anything more than 20 pounds. C. Inform client that there may be pain not relieved with pain medication. D. Stress the importance of having daily bowel movements.

Correct Answer is ["A","B","C","D"]

Explanation

The information that the nurse should include in the discharge teaching for the client who is three days post-operative abdominal aortic aneurysm repair is as follows:

Notify the healthcare provider (HCP) of any redness or irritation of the incision: This is important because redness or irritation can be signs of infection or other complications at the surgical site. Prompt reporting allows for early intervention and management.

Do not lift anything more than 20 pounds: Following abdominal aortic aneurysm repair, it is crucial to avoid heavy lifting or straining as it can put excessive pressure on the surgical site and potentially lead to complications such as incisional hernia. Restricting lifting to no more than 20 pounds helps to protect the incision and promote proper healing.

Inform the client that there may be pain not relieved with pain medication: Pain management is an essential aspect of post-operative care. However, it is important for the client to understand that complete relief of pain may not always be achievable with pain medication alone. They should be aware that mild to moderate discomfort may persist during the healing process, but severe or worsening pain should be reported to the healthcare provider.

Stress the importance of having daily bowel movements: After abdominal surgery, it is common for bowel movements to be delayed due to factors such as anesthesia, reduced activity, and pain medication. However, it is crucial for the client to maintain regular bowel movements to prevent constipation and potential complications such as bowel obstruction. The nurse should provide guidance on strategies to promote regular bowel function, such as staying hydrated, eating a balanced diet rich in fiber, and using stool softeners or gentle laxatives as directed by the healthcare provider.

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The nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

Correct Answer is B

Explanation

The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

Correct Answer is ["A","B","C","D"]

Explanation

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The nurse is teaching a client with peripheral arterial disease. Which information should the nurse include in the teaching plan?