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 D

Explanation

A. Timolol eye drops are not indicated following the administration of atropine, as atropine has no effect on intraocular pressure.
B. Inserting an indwelling catheter is not necessary for the administration of atropine, which is used to treat bradycardia, not urinary retention.
C. Administering an antidiarrheal medication is unrelated to atropine administration; atropine typically causes dry mouth rather than diarrhea.
D. Atropine is an anticholinergic medication that decreases saliva production, which can lead to dry mouth and discomfort. Frequent oral care is important to prevent oral mucosal irritation and discomfort for the client.

A. hypermagnesemia. B. hypocalcemia. C. hypokalemia, D. hyperglycemia

Correct Answer is C

Explanation

A. Hypermagnesemia can cause bradycardia and hypotension, but it is less commonly associated with PVCs. This does not align with the lab results provided.
B. Hypocalcemia can cause arrhythmias, but it is not the most likely cause of PVCs in this case, considering other findings.
C. Hypokalemia (low potassium) is a known cause of PVCs. The patient's potassium level is 2.8 mEq/L, which is significantly low and most likely contributing to the PVCs.
D. Although hyperglycemia can affect cardiac function, it is less commonly linked to PVCs compared to electrolyte imbalances, such as hypokalemia.

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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:

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

			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

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

Correct Answer is D

Explanation

Correct Answer is C

Explanation

Labs

Company

Resources

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 administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

Labs

The nurse has provided teaching to a client who had an implantable cardioverter/defibrillator inserted. Which statement by the client indicates the need for further instruction?

The nurse is caring for a client receiving a heparin infusion for disseminated intravascular coagulation (DIC). Which of the following lab results would indicate a sub-therapeutic level? An activated partial thromboplastin time (aPTT) of :……. (normal value: 25-35 seconds)

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

The nurse is caring for a client in the coronary care unit and the monitor depicts the rhythm shown below. What is the nurse’s interpretation of this rhythm?

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?