A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for
surgical placement of a permanent pacemaker. The client asks the nurse how this device will
help him. How should the nurse explain the action of a synchronous pacemaker? - ANSAn
electrical stimulus is discharged when no ventricular response is sensed.
-
The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal
conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial
fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse
generated on demand or as needed according to the patient's intrinsic rhythm) send an
electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract
when no ventricular depolarization is sensed.
The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, what position should the nurse ask the
client to demonstrate? - ANSExtend the arm, dorsiflex the wrist, and extend the fingers.
-
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction
should the nurse provide the client to reduce the risk of spreading the infection to other areas of
the client's urinary tract? - ANSHave intercourse or masturbate at least twice a week.
-
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for
microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate
regularly through intercourse or masturbation decreases the number of microorganisms present
and reduces the risk for further infection from stored contaminated seminal fluids.
Which action should the nurse implement on the scheduled day of surgery for a client with type
1 diabetes mellitus (DM)? - ANSObtain a prescription for an adjusted dose of insulin.
-
Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO
for scheduled surgery should receive a prescribed adjusted dose of insulin.
A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side
effect should the nurse provide to the client about this medication? - ANSGastrointestinal
disturbance.
-
,Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such
as nausea and gastric burning. It is recommended that this drug be taken with food to avoid
gastrointestinal upset.
The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse
determines the client's lower abdomen is distended and assesses dullness to percussion. What
is the priority nursing action? - ANSDetermine the time the client last voided.
-
Swelling at the surgical site in the immediate postoperative period can impact the bladder and
prostate area causing the client to experience difficulty voiding due to pressure on the urethra.
To provide additional data supporting bladder distention, the last time the client voided should
be determined next.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment,
what information is important to include? - ANSDry, itchy skin changes may occur.
-
Side effects from radiation to the breast most often include temporary skin changes such as:
dryness, tenderness, redness, swelling, and pruritis.
Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client
who experienced a burn injury during a house fire? - ANSCherry red color to the mucous
membranes.
-
The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen
molecules and the subsequent vasodilation induced cherry red color of the mucous membranes
is an indication of carbon monoxide poisoning.
What assessment finding should the nurse identify that indicates a client with an acute asthma
exacerbation is beginning to improve after treatment? - ANSWheezing becomes louder.
-
In an acute asthma attack, air flow may be so significantly restricted that breath sounds and
wheezing is diminished. If the client is successfully responding to bronchodilators and
respiratory treatments, wheezing should become louder as the air flow increases in the airways.
As the airways open and mucous is mobilized in response to treatment, the cough should
become more productive.
The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops
Mycobacterium avium complex (MAC). What is the most significant desired outcome for this
client? - ANSReturn to pre-illness weight.
-
, MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC
is a major contributing factor to the development of wasting syndrome, so the most significant
desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral
supplementation as needed.
The nurse obtains a client's history that includes right mastectomy and radiation therapy for
cancer of the breast 10 years ago. Which current health problem should the nurse consider is a
consequence of the radiation therapy? - ANSPathologic fracture of two ribs on the right chest.
-
The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the
occurence of two right-sided ribs with pathological fractures resulting without evidence of trauma
is related to radiation damage.
A client is admitted to the emergency department after being lost for four days while hiking in a
national forest. Upon review of the laboratory results, the nurse determines the client's serum
level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the
nurse make? - ANSExposure to cold environmental temperatures.
-
TSH influences the amount of thyroxine secretion which increases the rate of metabolism to
maintain body temperature near normal. Prolonged exposure to cold environmental
temperatures stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which
increases anterior pituitary serum release of TSH.
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis.
What is the priority nursing diagnosis for this client? - ANSImpaired comfort.
-
In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing
the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic
vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal
infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and
dyspareunia, which supports the primary nursing diagnosis, "Impaired comfort".
The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic
gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a
gastrostomy tube (GT). Which explanation best describes how they are different? - ANSMethod
of insertion.
-
The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT
insertion involves making an incision in the wall of the abdomen and suturing the tube to the
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