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 : B,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. Handheld metal detectors can interfere with pacemaker function, so it is safer to request a manual search at security checkpoints.
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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Correct Answer is ["B","C","E"]

Explanation

A. Increase in hematocrit is not expected in fluid overload; it generally decreases due to dilution of blood components.

B. Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress.

C. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system.

D. Increased temperature is not a typical finding in fluid overload; it might be associated with infection or inflammation instead.

E. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.

A. The client states having nasal congestion. B. The client states having a severe headache. C. The client's blood pressure becomes elevated. D. The client's bladder becomes distended.

Correct Answer is D

Explanation

A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.

B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.

C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.

D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is D

Explanation

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