A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed with second-degree AV block type II. Which of the following will be included in this client's treatment? (Select all that apply.)
1. Administer digoxin
2. Administer antiemetic
3. Administer atropine sulfate
4. Insert external pacemaker
5. Decrease intravenous fluids
6. Lower the head of the bed
3, 4
For second-degree AV block type II, treatment will almost always consist of external pacemaker insertion. Atropine sulfate may be used to increase the heart rate until the pacemaker can be inserted. Digitalis toxicity can cause this heart rhythm so digoxin should not be administered to this client. An antiemetic will not solve the client's underlying problem. The client may or may not need additional fluids. Lowering the head of the bed could compromise this client's respiratory status and should not be done.
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A mother brings her child into the clinic and states, "My child has had a fever the past few days because the skin has felt warm." Which response should the nurse provide the mother?
A. "The skin temperature changes when the temperature in our surroundings changes." B. "The only way to reliably assess the temperature with your hand is by feeling the forehead." C. "The temperature of the skin is not related to what is occurring inside the body." D. "When the skin feels warm, it means our blood vessels are constricted."