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 C

Explanation

A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.

A. “I probably will not have any transfusion reactions from my own blood." B. “This is the blood I've been giving for the past 6 weeks for myself. C. "I understand there is still a risk I can get hepatitis from this blood." D. "Since I have O negative blood, it's a good thing I'm getting my own blood."

Correct Answer is C

Explanation

A. “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B. “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C. An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D. “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.

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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

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

Correct Answer is C

Explanation

The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

Correct Answer is C

Explanation

The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

The nurse is caring for a client who is in the later stages of left-sided heart failure. Which chief complaint would the nurse expect the client to report?

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

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

A patient is to receive a continuous infusion of Diltiazem at 5 mg/hr for Atrial fibrillation. The medication is supplied 125 mg of Diltiazem in 125 mL of Iv fluid. At what rate should the nurse set the IV pump? (round to the nearest whole number)

The nurse is caring for a client diagnosed with acute heart failure on the telemetry unit. Which laboratory result does the nurse know is most indicative of this diagnosis?