The nurse is caring for a patient with an implanted pacemaker. While observing the cardiac monitor, the nurse notes extra pacer spikes that are not followed by a heartbeat. The nurse suspects which condition?
• Failure to capture is when the pacer fires a signal, but the heart does not respond with a beat. This is often caused by pacer lead migration on the epicardium.
• Incorrect: Failure to pace is when the pacer fails to fire a signal when it should. This often leads to bradycardia and hypotension because the heart cannot beat at the same rate as the pacer.
• Incorrect: Failure to sense is when the pacer cannot sense the heartbeat, leading to poorly-timed firing by the pacer.
• Incorrect: Asystole is the absence of a heart rate.
The nurse is performing a physical assessment on a patient with chronic obstructive pulmonary disease (COPD). Which of the following signs and symptoms should the nurse expect to find?
A patient is admitted to the emergency department due to unexplained lethargy. The nurse notes that the patient's breath has a fruity odor and suspects
The nurse is providing instruction to a client with type 1 diabetes on preventing diabetic ketoacidosis during acute infection. Which of the following statements, if made by the client, indicates a need for further instruction?
The nurse is informing a patient about postural drainage. To facilitate clearing of the lungs, the nurse should position the patient based on which assessment?
A patient with Raynaud's disease is admitted to the hospital with cyanotic fingers and extreme pain. The nurse understands that these symptoms are associated with
Which nursing diagnosis is most appropriate for a patient with a new onset of diabetes mellitus type II, who is making frequent trips to the vending machine for candy and soda?
A patient is experiencing frequent runs of ventricular tachycardia. The nurse should obtain an order from the provider to check serum levels of
A patient recently diagnosed with hyperthyroidism is receiving instructions from the nurse. The nurse should encourage the patient to
The nurse is caring for a patient at risk for premature ventricular contractions (PVCs). While monitoring the patient's electrocardiogram (EKG) rhythm, the nurse should look for
A patient has a skin lesion on his shoulder. The nurse would suspect melanoma if the lesion had which of the following characteristics?
A patient has undergone a skin biopsy. After the procedure, the nurse should instruct the patient to:
A 30-year-old patient was rescued from a burning house. However, the patient has sustained major burns on the anterior thorax, head and bilateral upper extremities. What is the initial treatment goal for this patient?
A nurse is providing education to a patient with acne. The nurse determines that the patient requires additional instruction if the patient states which of the following?
During a health education session about risk factors for heart disease, the nurse is discussing the updated 2013 guidelines from the American College of Cardiology/America Heart Association (ACC/AHA), which include conventional risk factors, modifiable risk factors, and non-traditional risk factors. The nurse educator identifies which of the following as non-traditional cardiovascular risk factors?
The nurse is caring for a 16-year-old boy with multiple fractures. Around this age, people often experience closure of the epiphyses. After this occurs, which of the following is true?
The nurse is instructing a patient on the symptoms of hypertension. Additional education is required if the patient states that which of the following is a symptom of high blood pressure?
The nurse is caring for a client with decreased cardiac output. Which of the following nursing actions should the nurse implement to monitor this client?
A patient returns to the nursing unit after undergoing a cardiac catheterization using the femoral insertion site. After the procedure, the nurse should avoid
A patient with progressive muscle weakness and poor balance is suspected of having muscular dystrophy. What test would the nurse expect the physician to order to confirm the diagnosis?
A patient has been diagnosed with left-sided congestive heart
After a cardiac catheterization procedure, the nurse monitors the client for which potential complications?
The nurse is concerned about impaired gas exchange in a patient with an inhalation injury. The nurse should avoid which of the following interventions?
The nurse is providing medical information to an adult patient with amyotrophic lateral sclerosis (ALS). The patient understands the nature of the disease if he or she asks which of the following questions?
A patient has been diagnosed with polycystic kidney disease (PKD). The nurse educates the patient on possible complications, including what most serious complication?
The nurse is preparing to administer IV insulin, dextrose, and sodium bicarbonate to a patient with acute renal failure. What is the nurse treating?
A patient is scheduled for a lumbar puncture. Which of the following statements indicates the patient understands the procedure?
Which of the following statements by a 25-year-old woman indicates that she understands breast self-examinations (BSE)?
The nurse is providing discharge instructions to a patient who had a total hip replacement. Which of the following patient statements indicates a need for additional instruction?
The nurse is caring for a patient with asthma and is instructing the patient on the proper use of a spacer device. Which of the following statements by the patient indicates the need for further instruction?
A patient is being cared for by a home-health nurse. The patient has jaundice and is complaining of pruritus. Which of the following interventions can the patient implement to reduce pruritus?