Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Assess the incision site for signs of infection

Apply a sling to the operative arm

Remove the pacemaker leads

Monitor vital signs regularly

Encourage vigorous physical activity

Answer and Explanation

Correct Answer : A,B,D

A.   Assess the incision site for signs of infection - This is an essential nursing intervention after any surgical procedure, including pacemaker insertion, to prevent and detect early signs of infection.
B.   Apply a sling to the operative arm - This helps to limit movement and prevent dislodging of the pacemaker leads, which is important for the healing process.
C.   Remove the pacemaker leads - This is not an appropriate intervention. The pacemaker leads are left in place after insertion to ensure proper function of the pacemaker.
D.   Monitor vital signs regularly - Regular monitoring of vital signs, especially heart rate and rhythm, is important to detect any complications such as arrhythmias after pacemaker insertion.
E.   Encourage vigorous physical activity - Vigorous physical activity should be avoided initially to prevent any strain or potential damage to the pacemaker or leads. Early mobility is important, but it should be gradual and restricted.

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Correct Answer is D

Explanation

A. Timolol eye drops are not indicated following the administration of atropine, as atropine has no effect on intraocular pressure.
B. Inserting an indwelling catheter is not necessary for the administration of atropine, which is used to treat bradycardia, not urinary retention.
C. Administering an antidiarrheal medication is unrelated to atropine administration; atropine typically causes dry mouth rather than diarrhea.
D. Atropine is an anticholinergic medication that decreases saliva production, which can lead to dry mouth and discomfort. Frequent oral care is important to prevent oral mucosal irritation and discomfort for the client.

Correct Answer is ["11"]

Explanation

The patient weighs 121 lbs, which is approximately 55 kilograms (121 ÷ 2.2).

Next, multiply the patient's weight in kilograms by the dosage prescribed, which is 20 units/kg. This results in a total dosage of 1100 units (55 kg × 20 units/kg).

The medication is supplied as 25,000 units in 250 mL, so to find out how many mL of medication is needed, set up a proportion: 25,000 units is to 250 mL as 1100 units is to X mL. Solving for X gives you 11 mL (1100 units × 250 mL ÷ 25,000 units).

Therefore, the nurse will administer 11 mL of Heparin to the patient.

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Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

Correct Answer is D

Explanation

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

Correct Answer is ["11"]

Explanation

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