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When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply.
- A. Take and record daily pulse rate.
- B. Avoid air travel because of airport security alarms.
- C. Immobilize the affected arm for 4 to 6 weeks.
- D. Avoid using a microwave oven.
- E. Avoid lifting anything heavier than 3 lb.
Correct Answer: A,E
Rationale: Daily pulse checks (A) monitor pacemaker function, and avoiding heavy lifting (>3 lb, E) prevents lead dislodgement. Air travel and microwaves are safe with modern pacemakers.
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A client with acute renal failure has edema. The nurse should:
- A. Elevate the legs.
- B. Restrict fluids.
- C. Administer a diuretic.
- D. Increase sodium intake.
Correct Answer: B
Rationale: Fluid restriction helps manage edema in acute renal failure.
Which action is contraindicated for a client with a risk of increased ICP?
- A. Elevate head of bed.
- B. Administer mannitol.
- C. Encourage coughing.
- D. Monitor neurological status.
Correct Answer: C
Rationale: Coughing is contraindicated as it increases intracranial pressure.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
The nurse is teaching a client with osteoporosis about fall prevention. Which of the following should be included? Select all that apply.
- A. Remove loose rugs from the home.
- B. Install grab bars in the bathroom.
- C. Wear high-heeled shoes for support.
- D. Ensure adequate lighting at night.
- E. Exercise regularly to improve balance.
Correct Answer: A,B,D,E
Rationale: Removing rugs, installing grab bars, ensuring lighting, and exercising prevent falls. High-heeled shoes increase fall risk.
A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
- A. PaCO2.
- B. HCO3.
- C. PaO2.
- D. pH
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.