A nurse is caring for a newly admitted client with an aortic dissection. The nurse proceeds to implement new orders, which of the following is appropriate for this client?

Opioid therapy

Promote a quiet environment by clustering care

Encourage heavy weight lifting for physical activity

Answer and Explanation

The Correct Answer is B

Choice A reason: Opioid therapy may be used for pain in aortic dissection but is not the most appropriate primary intervention. Controlling blood pressure and heart rate to prevent dissection progression is critical, and a quiet environment supports this by reducing stress and sympathetic activation, which could elevate pressure.

Choice B reason: Promoting a quiet environment by clustering care is appropriate for aortic dissection. Minimizing stress and activity reduces blood pressure and heart rate, preventing further tearing of the aortic wall. Clustering care limits disturbances, stabilizing hemodynamics and supporting medical management to prevent dissection progression.

Choice C reason: Encouraging heavy weight lifting is contraindicated in aortic dissection, as it increases blood pressure and shear stress on the aortic wall, risking further dissection or rupture. Physical activity must be restricted, and a calm environment is prioritized to maintain hemodynamic stability and prevent catastrophic complications.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Counting the pulse for 60 seconds daily helps monitor pacemaker function, ensuring it maintains the prescribed heart rate. This allows early detection of device malfunction, such as failure to pace, which could lead to bradycardia or inadequate cardiac output, supporting safe post-implantation care.

Choice B reason: Avoiding a microwave oven in the home is unnecessary, as modern pacemakers are shielded against electromagnetic interference from household appliances. This outdated restriction does not apply, and clients can safely use microwaves without risking device malfunction, making this instruction incorrect for pacemaker care.

Choice C reason: Notifying airport security of the pacemaker is essential, as metal detectors may trigger alerts, and security wands could interfere with device function. Informing security ensures safe screening methods (e.g., pat-downs) are used, preventing potential pacemaker disruption and ensuring safe travel for the client.

Choice D reason: Resuming physical activities that cause bumping or jolting should be avoided, as they risk dislodging pacemaker leads or damaging the device, especially early post-implantation. Such activities could cause lead displacement, leading to ineffective pacing or arrhythmias, making this an inappropriate instruction.

Choice E reason: Avoiding tight clothing over the insertion area is correct, as it prevents pressure on the pacemaker site, reducing irritation, infection risk, or lead dislodgement. Loose clothing promotes healing and device stability, ensuring proper function and comfort during the post-implantation recovery period.

A. The client’s ECG tracing shows irregular heart rate without P waves B. The client’s urine output is cloudy and odorous C. The client develops slurred speech D. The client has an aPTT of 80 seconds

Correct Answer is C

Explanation

Choice A reason: An irregular heart rate without P waves is characteristic of atrial fibrillation, not an acute priority in this context. While it confirms the diagnosis, it is an expected finding and does not indicate an immediate life-threatening complication compared to new neurological symptoms in a client on heparin.

Choice B reason: Cloudy, odorous urine suggests a urinary tract infection, which is concerning but not the priority. Infections require treatment, but new neurological symptoms like slurred speech in a client on heparin suggest a possible stroke or bleed, which is more urgent and life-threatening.

Choice C reason: Slurred speech in a client on heparin is the priority, as it may indicate a hemorrhagic stroke or transient ischemic attack, both critical complications. Heparin increases bleeding risk, and new neurological symptoms suggest possible intracranial hemorrhage, requiring immediate assessment and intervention to prevent further brain damage.

Choice D reason: An aPTT of 80 seconds is within the therapeutic range for heparin (typically 60–80 seconds), indicating effective anticoagulation. While monitoring is necessary, it is not a priority over new neurological symptoms like slurred speech, which could signal a life-threatening complication requiring urgent attention.

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A nurse is caring for a newly admitted client with an aortic dissection. The nurse proceeds to implement new orders, which of the following is appropriate for this client?

Nursing Test Bank

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