A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply)
“Until your incision is healed, do not submerge your pacemaker. Only take showers.”
“Report any pulse rates lower than your pacemaker settings.”
“If you feel weak, apply pressure over your generator.”
“Have your pacemaker turned off before having magnetic resonance imaging (MRI).”
“Do not lift your left arm above the level of your shoulder for 8 weeks.”
Correct Answer : A,B,E
Choice A reason: Avoiding submersion until the incision heals prevents infection in a new pacemaker site. This aligns with post-implant care, making it a correct instruction the nurse would include to ensure proper healing and device safety for the client.
Choice B reason: Reporting pulse rates below pacemaker settings indicates potential device failure, requiring prompt evaluation. This aligns with pacemaker monitoring, making it a correct instruction the nurse would teach the client to ensure device function and cardiac stability.
Choice C reason: Applying pressure over the generator doesn’t address weakness and may harm the device. Reporting low pulse rates is correct, making this incorrect, as it’s not a valid instruction for the nurse to include in pacemaker teaching.
Choice D reason: Pacemakers aren’t turned off for MRI; MRI-compatible devices or alternatives are used. Arm movement restriction is correct, making this incorrect, as it’s inaccurate compared to the nurse’s proper instructions for pacemaker care and MRI safety.
Choice E reason: Avoiding arm lifting above the shoulder for 8 weeks prevents lead dislodgement in a new pacemaker. This aligns with post-implant restrictions, making it a correct instruction the nurse would include to protect the device’s integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing breaths follows compressions in ACLS after defibrillation for pulseless ventricular tachycardia. Resuming compressions is immediate, making this incorrect, as it delays the nurse’s priority to restore circulation post-shock in the client’s code situation.
Choice B reason: Assessing the pulse occurs after 2 minutes of compressions, not immediately post-defibrillation. Resuming compressions is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on continuing CPR in pulseless ventricular tachycardia.
Choice C reason: Resuming chest compressions immediately after defibrillation maintains circulation in pulseless ventricular tachycardia per ACLS guidelines. This aligns with code management, making it the correct next step for the nurse to perform to optimize the client’s resuscitation efforts.
Choice D reason: Epinephrine is given after the second shock or per protocol, not immediately post-defibrillation. Compressions are the priority, making this incorrect, as it’s not the next step in the nurse’s ACLS sequence for managing the client’s arrhythmia.
Correct Answer is A
Explanation
Choice A reason: Malodorous flatus 2 days post-colostomy is normal, indicating bowel function resumption. This aligns with postoperative colostomy expectations, making it the correct interpretation by the nurse, as flatus is an expected milestone in the client’s recovery process.
Choice B reason: Ischemic bowel causes pain, fever, or absent output, not just malodorous flatus, which is normal post-colostomy. This is incorrect, as it misinterprets a typical finding as a serious complication in the nurse’s assessment of the client’s stoma.
Choice C reason: Flatus doesn’t indicate the need for a nasogastric tube, which is used for obstruction or ileus. Normal flatus is expected, making this incorrect, as it wrongly suggests intervention for a typical post-colostomy finding in the nurse’s evaluation.
Choice D reason: Malodorous flatus is unrelated to preoperative bowel preparation; it’s a normal post-colostomy event. This is incorrect, as it misattributes a standard recovery sign to surgical preparation, unlike the nurse’s correct interpretation of expected bowel function.
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