A patient has a pacemaker set at 72 beats/min. The nurse obtains a heart rate of 62 beats/min. What action should the nurse take?
a. Review pacemaker documentation.
b. Palpate and observe the generator site.
c. Administer the patient's scheduled digoxin dose.
d. Notify the registered nurse (RN) to inform the physician.
ANS: D
The nurse should notify the RN if the pacemaker is five beats over or under the set pacemaker rate for physician notification, as the pacemaker is not functioning properly. A. B. C. These actions could delay detecting a potentially unsafe situation for the patient.
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A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. The priority nursing action is to:
1. Obtain a nutritional history for each of these adolescents. 2. Refer these adolescents to the school psychologist. 3. Call the respective parents to discuss the eating patterns of each adolescent. 4. Speak with the girls in a group to discuss the problems associated with anorexia nervosa.
The nurse notes that an older client has a light grey ring around the iris. Which should the nurse attribute the finding to?
A. Loss of pigmentation in the iris. B. Pterygium. C. Deposition of lipids. D. Cataract formation.
The nurse caring for a newly admitted client recognizes that the client's past chart at an acute care facility is considered to be the
A) Primary source B) Secondary source C) Subjective data D) Nursing diagnosis
A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy?
a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with fresh pineapple and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with sweet corn and soda