Nokea
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
- A. The client's cardiovascular status.
- B. The client's emotional state.
- C. The type of sedation used.
- D. Pacemaker rate, type, and settings.
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
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A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.
Chemical cardioversion is prescribed for the client diagnosed with atrial fibrillation. The nurse who is assisting in preparing the client should expect that which medication specific for chemical cardioversion would be prescribed?
- A. Lidocaine
- B. Nifedipine
- C. Amiodarone
- D. Nitroglycerin
Correct Answer: C
Rationale: Amiodarone is an antidysrhythmic that is useful in restoring normal sinus rhythm for the client experiencing atrial fibrillation. Lidocaine is used for control of ventricular dysrhythmias. Both nifedipine and nitroglycerin are vasodilators and are prescribed for the restoration of a normal sinus rhythm.
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
- A. Assess the patency of the Foley catheter
- B. Assess urine for excessive bleeding
- C. Assess urine for excessive bleeding
- D. Obtain a urine specimen for culture
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs?
- A. Nausea
- B. Dizziness
- C. Sore throat
- D. Drowsiness
Correct Answer: C
Rationale: Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse reactions include blood dyscrasias. If the client develops a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the primary health care provider should be notified.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.