Question

1. A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?

1. Sneezing
2. Presence of intrinsic P waves following a QRS complex on the ECG
3. Hiccups
4. Presence of a sharp spike prior to the QRS complex on the ECG

2. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?

1. High-Fowler's
2. Feet elevated
3. Reverse Trendelenburg
4. Side-lying

3. A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

1. "I'll remove the soiled tracheostomy ties prior to cleaning my stoma."
2. cleanse the cannula with half-strength hydrogen peroxide."
3. "I'll insert the obturator after cleaning my stoma."
4. "I'll cut a slit in a clean gauze pad to use as a stoma dressing.

Answer 1

Answer@1@ (C) Hiccups.

After Permanent Pacemaker implant, if the pt have Hiccups , the Nurse should do further Assessment to find out that pacemaker is properly working or Not. Because Recurrent Hiccups after permanent Pacemaker Implant are suggestive of Pacemaker Malfunction or failure.

Answer@2@  

B-symptoms are of cardiogenic shock. Elevating legs above ❤️ helps move the blood from lower extremities to heart, brain and other important/vital organs

Answer @3@ B

A- wrong. You clean everything 1st before changing the tie and its a new trach
C-you do not insert back an obulator
D- cutting the gauze in the middle can increase possibilities of infection, prevention of contaminating wound.