Question

the nurse is assigned the following clients venous thrombosis

NCLEX-RN TEST- Diamonique Swanson Qld: 34987 (1460501) Notes Calculator Feedback The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? O 1. Assess incision for bleeding or hematoma formation O 2. Auscultate bilateral anterior and posterior lung sounds O3. Initiate continuous cardiac monitoring O 4. Reestablish IV fluids and postoperative antibiotics Submit

Answer 1

3 Continuous EKG monitoring ,noting HR ,pacemaker dependence,presence or absence of atrial and ventricular pacing vs intrinsic rythm .Atleast every 1-4 hours depending on patient stability ,phase of recovery i.e fresh post-operative or rehabilitation and hospital guidelines the following checks should be performed and documented such as vital signs