A nurse is teaching 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)

Do not have a microwave oven in the home.

Request to be scanned with a handheld metal detector when in the airport.

Count your pulse for 1 min each morning.

Do not wear tight clothing over the insertion area.

Resume activities that can cause jolting, such as horseback riding, after 4 weeks.

Answer and Explanation

Correct Answer : C,D

A. Modern pacemakers are designed to withstand interference from microwave ovens, so it is not necessary to avoid having them in the home.
B. Airport security staff should be informed about the pacemaker, but handheld metal detectors should be avoided because prolonged exposure can interfere with pacemaker function. Instead, the client should request a manual search.
C. Monitoring the pulse daily helps to ensure the pacemaker is functioning properly and to detect any irregularities early.
D. Wearing tight clothing over the insertion area can cause discomfort and may interfere with the function of the pacemaker.
E. Activities that involve jolting or the risk of impact to the pacemaker should be avoided until cleared by a healthcare provider, and this period may extend beyond 4 weeks.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

A. Ecchymosis indicates bruising but is not a primary parameter for assessing neurovascular status.

B. Skin integrity is important to monitor for any signs of breakdown or infection.

C. Temperature helps assess for adequate blood flow and potential complications.

D. Color of the extremity indicates blood flow and can show signs of compromised circulation.

E. Sensation checks for nerve damage or impaired circulation.

A. Secure the drain to the client's bed sheet. B. Expel the air from the JP bulb after emptying to re-establish suction. C. Measure the drainage every hour for the first 8 hr postoperative. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

Correct Answer is B

Explanation

A. Securing the drain to the client's bed sheet is not an appropriate method for securing the JP drain; it should be secured to the client’s gown or clothing to avoid tension on the drain.

B. Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.

C. Measuring the drainage every hour for the first 8 hr postoperative is more frequent than necessary; monitoring can be done every 4-8 hours depending on the protocol.

D. Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze is incorrect; the drain should be removed per the surgeon’s orders, and the site should be covered with a sterile dressing.

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A nurse is teaching 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)

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Naxlex Comprehensive Predictor Exams

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