Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Assess the incision site for signs of infection

Apply a sling to the operative arm

Remove the pacemaker leads

Monitor vital signs regularly

Encourage vigorous physical activity

Answer and Explanation

Correct Answer : A,B,D

A.   Assess the incision site for signs of infection - This is an essential nursing intervention after any surgical procedure, including pacemaker insertion, to prevent and detect early signs of infection.
B.   Apply a sling to the operative arm - This helps to limit movement and prevent dislodging of the pacemaker leads, which is important for the healing process.
C.   Remove the pacemaker leads - This is not an appropriate intervention. The pacemaker leads are left in place after insertion to ensure proper function of the pacemaker.
D.   Monitor vital signs regularly - Regular monitoring of vital signs, especially heart rate and rhythm, is important to detect any complications such as arrhythmias after pacemaker insertion.
E.   Encourage vigorous physical activity - Vigorous physical activity should be avoided initially to prevent any strain or potential damage to the pacemaker or leads. Early mobility is important, but it should be gradual and restricted.

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

Explanation

A. A patient with blood type A- can receive A- blood, as it matches both the ABO blood group and Rh factor.
B. A patient with A- blood cannot receive AB blood because the blood type is incompatible in terms of both ABO group and Rh factor. AB blood contains both A and B antigens, which could lead to an immune response in a type A patient.
C. O- blood is a universal donor for all blood types, meaning it does not contain A or B antigens and does not have the Rh factor, so it can be given to an A- patient.
D. As already noted, A- blood is compatible with an A- patient because both the ABO group and Rh factor are the same.
E. O+ blood contains the Rh antigen, and since the patient is A-, they cannot receive Rh-positive blood, as this could cause an immune reaction.

A. Increased respiratory race B. Increased temperature C. Increased heart rate D. Increased blood pressure E. Increase hematocrit

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

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL
Calcium	8.0 mg/dL	8.2-10.2 mg/dL:

Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient whose blood type is A-. The nurse knows that this patient can receive the following blood types:(SELECT ALL THAT APPLY)

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

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

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