Nokea
The nurse is caring for the client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the client’s plan of care to best prevent pacemaker lead dislodgement?
- A. Inspect the incision for approximation and bleeding
- B. Prevent the right arm from going above shoulder level
- C. Assist the client with using a walker when out of bed
- D. Request a STAT chest x-ray upon return from the procedure
Correct Answer: B
Rationale: Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the client to limit arm activity. Inspecting the incision, using a walker, and chest x-ray do not directly prevent lead dislodgement.
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The client’s BP is being taken at a screening clinic. Which client statement to the nurse demonstrates awareness of having a risk factor for hypertension?
- A. “My doctor told me my body mass index is 23 and my blood pressure is 118/70.”
- B. “I usually have a glass of wine to unwind when I come home from work.”
- C. “I plan to get my blood pressure checked more often, as I am African American.”
- D. “I have colds during the winter, so I plan to get the influenza vaccine every year.”
Correct Answer: C
Rationale: Being African American is a known risk factor for hypertension. Starting to have the BP taken more often demonstrates awareness of having a risk factor for hypertension. A BMI of 23 is normal, excessive alcohol intake increases risk but one glass is not excessive, and colds or flu vaccines do not directly relate to hypertension risk.
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
- A. A low-calorie regular diet
- B. A statin antilipidemic medication
- C. A thiazide diuretic medication
- D. Low-salt, low-saturated-fat, low-potassium diet
Correct Answer: B
Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.
The client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. Which statements, if made by the client, support the home-care nurse’s conclusion that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion? Select all that apply.
- A. “I have been doing exercises twice daily.”
- B. “All nicotine products were thrown away.”
- C. “These support hose keep my legs warm.”
- D. “I see a podiatrist tomorrow for foot care.”
- E. “I'm following a low-saturated-fat diet”
- F. “I now take rosuvastatin calcium.”
Correct Answer: A;B;E;F
Rationale: The client’s statements indicating lifestyle changes are: A) Exercising to promote collateral circulation; B) Discontinuing nicotine to deter atherosclerosis; E) Following a low-saturated-fat diet to reduce atherosclerosis; F) Taking rosuvastatin to lower cholesterol. Support hose and podiatry care do not directly prevent restenosis.
The client is scheduled for a coronary artery bypass graft in one week. Which instructions should the nurse provide to the client? Select all that apply.
- A. Stop taking aspirin now and any products containing aspirin.
- B. Do perform aerobic exercises 30 minutes daily before surgery.
- C. Use the prescribed antimicrobial soap before hospital arrival.
- D. Shave your chest and legs and then shower to remove the hair.
- E. Resume normal activities when discharged from the hospital.
Correct Answer: A;C
Rationale: The nurse should instruct: A) Stop aspirin to reduce bleeding risk; C) Use antimicrobial soap to decrease infection risk. Aerobic exercises (B) may be too strenuous, shaving (D) is done just before surgery, and normal activities (E) are restricted post-surgery.
The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.