The nurse is caring for a client immediately following the insertion of a permanent pacemaker. Which intervention should be included in the plan of care?

Teach the client how to change the pacemaker dressing

Immobilize the affected arm using a sling

Arrange for ancillary personnel to feed the client

Monitor urine output every two hours

Answer and Explanation

The Correct Answer is B

A. Teach the client how to change the pacemaker dressing: Client education is important but not a priority in the immediate post-procedure phase. Dressing changes should initially be performed using sterile technique by clinical staff to prevent infection at the insertion site.

B. Immobilize the affected arm using a sling: After pacemaker insertion, the affected arm (usually on the side of the implantation) should be immobilized or limited in movement to prevent lead dislodgment. Elevating the arm above the shoulder or excessive motion can compromise pacemaker lead placement during the early healing period.

C. Arrange for ancillary personnel to feed the client: Assistance with feeding is only necessary if the client has physical or cognitive limitations. This is not a routine or priority intervention following pacemaker insertion unless clinically indicated by other assessments.

D. Monitor urine output every two hours: Frequent monitoring of urine output is not directly related to pacemaker insertion unless there are other concerns such as fluid imbalance or renal dysfunction. It's not a standard intervention in the immediate care plan for this procedure.

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Correct Answer is B

Explanation

A. Have blood drawn weekly to check for high magnesium levels: Lisinopril, an ACE inhibitor, does not significantly affect magnesium levels. Regular monitoring is more important for potassium and renal function (BUN/creatinine), especially in heart failure patients, not magnesium.

B. Avoid the use of salt substitutes in your diet: Lisinopril is an ACE inhibitor. ACE inhibitors can cause potassium retention by reducing the production of aldosterone. Many salt substitutes contain high amounts of potassium chloride and combining the two may lead to hyperkalemia. Patients should be instructed to avoid these substitutes unless approved by their provider.

C. Notify your physician if a headache develops: Headache is a relatively common and usually mild side effect of lisinopril. It does not typically warrant discontinuation or immediate provider notification unless it's severe or persistent with other symptoms like dizziness or visual changes.

D. Take your heart rate daily when on this medication: Lisinopril does not significantly affect heart rate. Monitoring blood pressure is more relevant, as ACE inhibitors are antihypertensives. Heart rate monitoring is more critical with beta blockers or calcium channel blockers.

A. Assessing the incision for any redness, swelling, or discharge B. Applying wet-to-dry dressings every 4 hours to the insertion site C. Reinforcing the pressure dressing as needed D. Encouraging range-of-motion exercises of the involved arm

Correct Answer is A

Explanation

A. Assessing the incision for any redness, swelling, or discharge: At 3 weeks post pacemaker insertion, the wound should be well into the healing process. Monitoring for signs of infection—such as redness, swelling, or discharge—remains a top priority to identify delayed wound complications like infection or erosion.

B. Applying wet-to-dry dressings every 4 hours to the insertion site: Wet-to-dry dressings are used for debridement of open wounds with significant drainage and necrotic tissue, not for healing surgical incisions. By 3 weeks post-procedure, the site should be dry and closed; such dressing changes would be inappropriate and potentially increase risk of infection.

C. Reinforcing the pressure dressing as needed: Pressure dressings are typically used in the immediate post-operative period to control bleeding and are not maintained weeks after insertion. Reinforcing one at this stage would suggest poor wound healing or inappropriate post-op management.

D. Encouraging range-of-motion exercises of the involved arm: While regaining full range of motion is important after pacemaker insertion, it's usually initiated gradually. Gentle arm movement may be resumed after a few weeks but early aggressive range-of-motion exercises are discouraged immediately post-insertion to prevent lead dislodgement. At the 3-week mark, movement should be cautious and per the provider’s specific clearance.

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Potassium 2.8 mEq/L
Sodium 133 mEq/L
Chloride 90 mEq/L
Glucose 200 mg/dl
Magnesium 2.5 mg/dL
Calcium 8.0 mg/dL

The nurse is caring for a client immediately following the insertion of a permanent pacemaker. Which intervention should be included in the plan of care?

Nursing Test Bank

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