The occupational health nurse is evaluating a patient who is 3 weeks post pacemaker insertion. Which nursing intervention is MOST appropriate at this time?
Assessing the incision for any redness, swelling, or discharge
Applying wet-to-dry dressings every 4 hours to the insertion site
Reinforcing the pressure dressing as needed
Encouraging range-of-motion exercises of the involved arm
The Correct Answer is A
A. Assessing the incision for any redness, swelling, or discharge: At 3 weeks post pacemaker insertion, the wound should be well into the healing process. Monitoring for signs of infection—such as redness, swelling, or discharge—remains a top priority to identify delayed wound complications like infection or erosion.
B. Applying wet-to-dry dressings every 4 hours to the insertion site: Wet-to-dry dressings are used for debridement of open wounds with significant drainage and necrotic tissue, not for healing surgical incisions. By 3 weeks post-procedure, the site should be dry and closed; such dressing changes would be inappropriate and potentially increase risk of infection.
C. Reinforcing the pressure dressing as needed: Pressure dressings are typically used in the immediate post-operative period to control bleeding and are not maintained weeks after insertion. Reinforcing one at this stage would suggest poor wound healing or inappropriate post-op management.
D. Encouraging range-of-motion exercises of the involved arm: While regaining full range of motion is important after pacemaker insertion, it's usually initiated gradually. Gentle arm movement may be resumed after a few weeks but early aggressive range-of-motion exercises are discouraged immediately post-insertion to prevent lead dislodgement. At the 3-week mark, movement should be cautious and per the provider’s specific clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assist the client from the stretcher to a wheelchair: Immediately after electroconvulsive therapy (ECT), the client is still recovering from anesthesia and may experience confusion, drowsiness, or muscle weakness. Transferring the client prematurely poses a fall risk and is not appropriate as the first action.
B. Orient the client and offer reassurance: While reorientation and reassurance are important aspects of post-ECT care, safety and physiological stability must be assessed first. This action should follow an initial assessment of vital signs and level of consciousness.
C. Encourage the client to drink some fluids: Offering fluids too soon after ECT is inappropriate because the client may have impaired swallowing reflexes from anesthesia or sedation. Ensuring the airway is clear and the client is fully alert must precede oral intake.
D. Assess vital signs and orient client to the PACU environment: The priority after any procedure involving anesthesia is to assess vital signs to ensure hemodynamic stability and monitor for complications. Once stable, the nurse can begin to orient the client, which is often needed after ECT due to temporary disorientation or memory lapses.
Correct Answer is B
Explanation
A. Cardiovert in the synchronized mode: Synchronized cardioversion is used for hemodynamically unstable but conscious patients with rhythms like atrial fibrillation or supraventricular tachycardia. It is not appropriate for a pulseless patient with ventricular fibrillation, as synchronization requires detectable R-waves.
B. Defibrillate immediately with a biphasic machine: The rhythm strip shows ventricular fibrillation (VF) a life-threatening arrhythmia characterized by chaotic, irregular waveform with no identifiable PQRST and no effective cardiac output. The patient is unresponsive and pulseless, making immediate defibrillation the priority action, as per Advanced Cardiac Life Support (ACLS) guidelines.
C. Take a full set of vital signs: The client is already unresponsive and pulseless, making a full set of vitals irrelevant at this moment. Immediate resuscitation efforts, including defibrillation and CPR, take priority.
D. Initiate cardiopulmonary resuscitation: While CPR is a critical part of the algorithm for pulseless rhythms, defibrillation is the first priority in ventricular fibrillation when a defibrillator is available and ready. CPR should be started immediately after the shock if no pulse returns.
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