Nokea
A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to:
- A. Maintain skin integrity.
- B. Maintain cardiac conduction stability.
- C. Decrease cardiac output.
- D. Increase activity level.
Correct Answer: B
Rationale: Maintaining cardiac conduction stability is the priority post-pacemaker insertion to ensure the device effectively manages bradycardia.
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When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
- A. Epigastric pain at night.
- B. Relief of epigastric pain after eating.
- C. Vomiting.
- D. Weight loss.
- E. Melena.
Correct Answer: A,C,E
Rationale: Gastric ulcers commonly cause epigastric pain at night, vomiting, and melena (dark, tarry stools) due to bleeding. Relief of pain after eating is more typical of duodenal ulcers, and weight loss is less common with gastric ulcers.
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Preventing constipation avoids straining, which could increaseSy to dislodge packing or cause bleeding. Showering is safe if precautions are taken. Coughing or nose-blowing could disrupt healing. The correct answer is based on preventing complications post-nasal surgery.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.