ATI MED SURG EXAM RETAKE WITH RATIONALE

INCORRECT 3) Hypertension INCORRECT 4) High calcium intake 5) Immobility Answer Rationale: Dehydration is correct. Dehydration increases the blood's viscosity, thus increasing the risk for clot formation.Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives.Hypertension is incorrect. Hypertension does not increase the risk for clot formation.High calcium intake is incorrect. High calcium intake does not increase the risk for clot formation.Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation. 32. A nurse is assisting with the care of a client who is postoperative following a cardiac catheterization via the femoral artery. Which of the following actions should the nurse take? (Select all that apply.) 1) Check peripheral pulses in the affected extremity. INCORRECT 2) Place the client in high-Fowler's position. INCORRECT 3) Measure the client's vital signs every 8 hr. 4) Keep the client's hip and leg extended. 5) Have the client remain in bed up to 6 hr. Answer Rationale: Check peripheral pulses in the affected extremity is correct. The nurse should check peripheral pulses, skin temperature, and color in the affected extremity.Place the client in high-Fowler's position is incorrect. The client should remain flat for 6 hr following the procedure.Measure the client's vital signs every 8 hr is incorrect. The nurse should measure the client's vital signs every 15 min for the first hr, every 30 min for 2 hr or until stable, and then every 1 hr until stable.Keep the client's hip and leg extended is correct. Preventing the leg and hip from flexing helps promote clot formation.Have the client remain in bed up to 6 hr is correct. The client should remain flat in bed for 6 hours following a cardiac catheterization via the femoral artery. 33. A nurse is reinforcing teaching for a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) 1) Count your pulse for 1 min each morning. INCORRECT 2) Count your respiratory rate for 1 min each morning. 3) Report hiccups to the provider. INCORRECT 4) Avoid metal detectors. INCORRECT 5) Do not operate microwave ovens. Answer Rationale: Count your pulse for 1 min each morning is correct. Clients who have a permanent pacemaker should count their heart rate daily, document the information, and report changes.Count your respiratory rate for 1 min each morning is incorrect. There is no need for clients who have a permanent pacemaker to record their respiratory rate.Report hiccups to the provider is correct. The client should report any indication the pacemaker is not functioning correctly, such as hiccups.Avoid metal detectors is incorrect. There is no danger to the client in going through a metal detector, but the client should inform airport personnel because the pacemaker will trigger an alarm.Do not operate microwave ovens is incorrect. It is safe for clients who have a pacemaker to operate microwave ovens unless the pacemaker is old and does not have the appropriate shielding or is defective.