The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion of maintenance fluid at a rate of 150 mL/hr, unchanged from the last 10 hours. The client's urine output for the last 3 hours has been 90ml, 50mL, and 24mL. Which nursing action is the priority?

Continue to monitor urine output

Call the primary health care provider

Check the urine specific gravity

Check the serum albumin level

Answer and Explanation

The Correct Answer is B

A.   While monitoring urine output is important, the significant decrease in urine output (90 mL, 50 mL, and 24 mL over the last 3 hours) suggests a potential issue that requires more immediate action.
B.   Given the decrease in urine output and the recent abdominal aortic aneurysm resection, it is crucial to inform the primary healthcare provider promptly. A significant drop in urine output could indicate acute renal failure or other serious complications that need immediate attention.
C.   Checking the urine specific gravity can provide information on the concentration of the urine and help assess the kidney’s ability to concentrate urine. However, while this information is useful for understanding fluid balance and renal function, it is not the immediate priority.
D.   Serum albumin levels can help assess the patient's nutritional status and the presence of possible fluid imbalances or protein loss. While important for overall patient management, serum albumin levels are not the immediate priority in the context of sudden and significant changes in urine output following a major surgical procedure.

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Correct Answer is C

Explanation

A. Meningitis is an infection of the protective membranes covering the brain and spinal cord (meninges). It is not directly related to mitral valve stenosis or other valvular heart diseases.
B. Haemophilus influenzae is a bacterium that can cause respiratory tract infections and other diseases such as meningitis, particularly in children. However, it is not a common cause of rheumatic fever or valvular heart disease.
C. Rheumatic fever is a serious complication of untreated or inadequately treated Group A Streptococcal pharyngitis (strep throat). It can cause inflammation in various parts of the body, including the heart. Rheumatic fever is a known cause of rheumatic heart disease, which can lead to mitral valve stenosis or regurgitation.
D. Varicella, commonly known as chickenpox, is a viral infection caused by the varicella-zoster virus. While it is important to manage and prevent viral infections, varicella is not associated with the development of mitral valve stenosis or other valvular heart diseases.

A. Avoid direct blows to the chest. B. Start lifting the arm above the shoulder right away to prevent a "frozen shoulder". C. Avoid cooking with microwave ovens. D. Use mild analgesics to control the chest spasms caused by the pacing current.

Correct Answer is A

Explanation

A. The pacemaker and its leads are implanted in the chest area, and direct blows or trauma to this area can potentially dislodge the leads or damage the pacemaker. Patients should be advised to avoid activities that could result in trauma to the chest to protect the pacemaker and ensure its proper function.
B. Patients are generally advised to avoid lifting the arm on the side of the pacemaker above shoulder level for a period (usually about 4-6 weeks) to prevent complications and ensure proper healing. Early lifting of the arm might dislodge the pacemaker leads or cause other issues. Exercises and range-of- motion activities are typically started under guidance once the initial healing period is over.

C. Modern pacemakers are designed to be shielded against common household electrical appliances, including microwave ovens. Patients with pacemakers do not need to avoid using microwave ovens, as there is no significant risk of interference from these devices.
D. Mild analgesics might be used for discomfort or pain in some cases, but the notion that chest spasms are caused by the pacing current is generally incorrect. Pacemakers are designed to be non-intrusive and should not cause spasm-like sensations if functioning correctly.

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Naxlex Comprehensive Predictor Exams

A 67-year-old patient will be undergoing a mitral valve replacement for severe mitral valve stenosis. When reviewing the patient's chart, which of these infectious diseases would likely to be present in this patient's history?

Correct Answer is C

Explanation

A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, what should the nurse include when teaching the patient?

Correct Answer is A

Explanation

A patient admitted with diagnosis of pericarditis develops hypotension, shortness of breath, tachycardia, distended neck veins. Which of the following procedures with the nurse anticipate assisting for this emergent situation?

What should the nurse teach the patient who has endocarditis about preventing recurrence of the infections?

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching?

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

A patient has been diagnosed with a 4cm abdominal aortic aneurysm. Which of the following conditions would indicate surgical intervention may be necessary?

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)