A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first?

Measure the client's blood pressure.

Prepare the client for temporary pacing.

Initiate IV fluid therapy for the client.

Administer atropine to the client.

Answer and Explanation

The Correct Answer is A

The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.

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Correct Answer is B

Explanation

The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.

The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.

A. A client who has a peripherally inserted central catheter (PICC) in the left arm B. A client who has a right upper extremity arteriovenous fistula C. A client who has right-sided weakness due to Parkinson's disease D. A client who has left-sided Bell's palsy

Correct Answer is B

Explanation

The nurse should obtain a blood pressure reading using only the left extremity from a client who has a right upper extremity arteriovenous fistula. An arteriovenous fistula is a surgical connection between an artery and a vein that is created for hemodialysis access.

Measuring blood pressure on the arm with an arteriovenous fistula can cause damage to the fistula, reduce blood flow, and increase the risk of infection or thrombosis. Therefore, blood pressure should be measured on the opposite arm or on another site such as the leg.

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A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first?

Nursing Test Bank

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