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 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 nurse is admitting the client experiencing dyspnea from HF and COPD with high CO2 levels. Which interventions should the nurse plan? Select all that apply.
- A. Apply oxygen 6 liters per nasal cannula.
- B. Elevate the head of the bed 30 to 40 degrees.
- C. Weigh daily in the am. after the client voids.
- D. Teach client pursed-lip breathing techniques.
- E. Turn and reposition the client every 1 to 2 hours.
Correct Answer: B;C;D
Rationale: The nurse should plan: B) Elevating the head of the bed to promote lung expansion; C) Daily weights to assess fluid retention; D) Pursed-lip breathing to conserve energy and slow breathing. High oxygen flow (A) may depress hypoxic drive in COPD, and repositioning (E) is less specific to dyspnea management.
The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply.
- A. Avoid eating an excess of dark green vegetables.
- B. Take rests and elevate the legs while sitting.
- C. Wear graduated compression stockings, removing them at night.
- D. Increase standing time and shift weight when upright.
- E. Sleep with legs elevated above the level of the heart.
Correct Answer: B;C;E
Rationale: The nurse should emphasize: B) Elevating legs when sitting to promote venous return; C) Wearing compression stockings to reduce edema; E) Sleeping with legs elevated to enhance venous return. Avoiding dark green vegetables is relevant only with anticoagulants, and prolonged standing should be avoided.
The nurse is assessing the client with an anterior-lateral MI. The nurse should add decreased cardiac output to the client’s plan of care when which finding is noted?
- A. Pain radiates up left arm to neck
- B. Presence of an S4 heart sound
- C. Crackles auscultated in both lung bases
- D. Vesicular breath sounds over lung lobes
Correct Answer: C
Rationale: An anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With decreased cardiac output, blood accumulates in the heart and backs up into the pulmonary system, causing fluid to move into interstitial spaces and alveoli, resulting in crackles. Pain radiation, S4 sounds, and vesicular breath sounds do not directly indicate decreased cardiac output.