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The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident?
- A. I will never be able to operate a microwave oven again.
- B. I should expect occasional feelings of dizziness and fatigue.
- C. I will take my pulse in the wrist or neck daily and record it in a log.
- D. Moving my arms and shoulders vigorously helps check pacemaker functioning.
Correct Answer: C
Rationale: Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the primary health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the primary health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.
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What should the pregnant client be taught to immediately eliminate in the first trimester to promote normal fetal organ development?
- A. Smoking
- B. Caffeine
- C. Alcohol
- D. Fatty foods
Correct Answer: C
Rationale: The first trimester, 'organogenesis,' is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this critical period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development. Although options 1, 2, and 3 may be concerns, they are not specifically associated with the first trimester of pregnancy.
When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client's safety?
- A. Monitor the client's urinary output.
- B. Assess the client for neurological problems.
- C. Ensure that the bed rails remain in the up position.
- D. Monitor the client's vital signs and electrocardiogram (ECG) frequently.
Correct Answer: D
Rationale: Flecainide is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. However, the nurse must monitor for the development of a new or worsening dysrhythmia. Options 1, 2, and 3 are components of standard care but are not specific to this medication.
The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?
- A. Ensure that the client is appropriately dressed.
- B. Administer an opioid analgesic 30 to 60 minutes before therapy.
- C. Schedule the therapy at a time when the client generally takes a nap.
- D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B
Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.