A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching?
a. "Do not submerge your pacemaker, take only showers."
b. "Report pulse rates lower than your pa-cemaker setting."
c. "If you feel weak, apply pressure over your generator."
d. "Have your pacemaker turned off before having an MRI."
B
The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min.
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The nurse is planning care for a client who has been admitted to the unit with a salicylate overdose. When preparing the plan of care, the nurse considers which to be a priority nursing diagnosis?
A) Ineffective Breathing Pattern B) Powerlessness C) Risk for Injury D) Impaired Mobility
A nurse is caring for a client who has hemophilia and experiences pain due to bleeding into the joints. Which of the following interventions would be appropriate for this client?
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The nurse teaches the breastfeeding mother that milk production can be increased during lactation by:
A) waiting longer between feedings, at least 4-6 hours. B) making sure the breast is completely empty at each feeding. C) feeding more often for shorter periods of time, alternating breasts. D) taking one estrogen tablet daily to boost levels and increase milk production.
An emergency department triage nurse receives a report that an incoming client has a Glasgow Coma Scale (GCS) score of 8. The nurse alerts the staff that the client's priority intervention is:
1. Assessment of airway, breathing, and circulation. 2. Re-assessment using the FOUR Score Consciousness Scale. 3. Introduction of an intravenous access device. 4. Establishment of orientation to time, place, and person.